Parish jails and state prisons have, in a sense, become paying customers for hospital treatment in Louisiana after decades of receiving free care for their inmates from charity hospitals that are now closed or privately run.

When the state began privatizing the charity hospital system in 2013, state and parish prisons lost their go-to outlet to treat the people held in their care.

This has been a particular complaint in recent months among East Baton Rouge Parish officials, who have acknowledged using the now-shuttered Earl K. Long Medical Center to treat not just emergency cases from the jail but also inmates with less serious medical problems.

While the charity hospitals used to receive state taxpayer money to treat prisoners for free, the bills for taking care of sick inmates now fall to city-parish governments or the state Department of Public Safety and Corrections.

The Corrections Department is now footing the bill for inmates — even the pretrial ones at parish prisons — who end up in emergency rooms or who need care from specialists, a state official said. But Baton Rouge Chief Administrative Officer William Daniel said the caveats to the deal are gaping, as the state agency can reject claims for hospital care that it deems medically unnecessary, and the bills then fall to local government.

This shift is causing growing pains and confusion among East Baton Rouge Parish jail officials and health care administrators over who is responsible for treatment, payment and management of prisoners’ medical care.

The new system also relies on the city-parish government stepping up to ensure that jail facilities offer robust primary and preventative care to keep inmates from needing expensive emergency room visits.

But nurses at the East Baton Rouge Parish Prison describe their medical facilities as anything but robust.

They have spent six months unsuccessfully trying to fill about six open positions for licensed practical nurses that would bring their staffing level to the proper levels. They struggle to afford supplies and have to devote long portions of their time to pill calls and other routine care for the more than 1,500 inmates held at the jail in north Baton Rouge.

They use refrigerators meant for college dorm rooms to refrigerate insulin and converted a nursing station to also serve as a private doctor/patient room and a place to run lab work. And they are increasingly called upon to treat mentally ill patients who wind up in Parish Prison for petty crimes because there is nowhere else for them to go.

“They struggle, understandably, because they’ve never had to do this before,” said Raman Singh, the medical and mental health director of the Department of Corrections, speaking about parish prison medical staffs.

Singh, a former doctor at Louisiana State Penitentiary at Angola, was instrumental in creating the new prisoner health care system. He said large parish jails, like the one in East Baton Rouge, need to step up to the plate and provide primary care services that treat physical and mental health.

“There’s no denying the fact that the closure of Earl K. Long hospital has put more work on the East Baton Rouge Parish Prison,” he said. “But it could have been worse.”

New system of care

Rintha Simpson, the interim prison health care manager, said DOC is the gatekeeper for the Parish Prison’s medical system, and she’s constantly trying to ensure the Parish Prison is following protocol and going to DOC for pre-approval.

Singh insists that the system today is better in nearly every way than the old one. It’s more efficient, it’s cheaper and it improves the quality of prisoner care, he said. And he sees it poised to continue to improve, as the Medicaid expansion promised by Gov. John Bel Edwards should cover more of the costs associated with inmate hospital admissions.

Between 2013 and 2014, around 66 percent of inmate hospital admissions were paid for by Medicaid. Singh and Daniel both hope that the number will reach 100 percent under the expansion.

Under the charity hospital system, Singh estimated, the state was paying $75 million a year for the network of public hospitals to cover prison medical care. For 2015-16, the Department of Corrections has budgeted only $30.2 million to pay for hospital prisoner care based on the lower costs it has paid out over the past few years.

While Singh said the new system shows the efficiencies based on the fewer dollars being allocated, Daniel questioned how $30 million could be enough to pay for the hospital care of every prisoner in the state.

East Baton Rouge Mayor-President Kip Holden’s office also allocated $4.86 million for EMS to run prison medical services at the Parish Prison in 2016. It’s unclear whether the new system of DOC paying for outpatient care will make a dent in the amount that the city-parish needs to spend.

EMS Administrator Chad Guillot estimates that agency spends between $1.4 million and $1.7 million a year on medications alone. While Guillot said he believes DOC is absorbing costs for hospital visits now, he said he has not received any official notification of it. After Earl K. Long hospital closed in 2013, Guillot said, EMS started receiving the bills for inmates who needed emergency room visits or appointments with specialists.

It was not until December 2015 that EMS stopped receiving bills from prisoners’ hospital visits, Guillot said.

Singh said government officials shouldn’t distinguish too much between the pots of money being tapped for prisoner medical care.

“Whether it’s the Mayor’s Office paying the bill or the Department of Corrections paying the bill, at the end of the day, it’s taxpayers paying the bill,” he said.

Singh said the agreement is that DOC is contracting with certain hospitals and doctors across the state. If a parish prison inmate needs to see a specialist, the agency will set up the appointment and pay the bill. If an inmate needs to go to an emergency room, DOC is alerted when they arrive.

The Corrections Department will reimburse the bill if it fits the criteria of what it deems a “medically necessary” emergency room visit, a rule Singh said has been put in place to stop the overuse of emergency rooms for non-emergency reasons. If DOC deems an ER visit not “medically necessary,” the agency that runs a parish prison’s health care services will be responsible for paying the bill.

Singh said DOC also now puts pressure on hospitals to treat inmates as quickly as possible. When the charity hospitals were absorbing the costs of care, he said, it did not cause problems for inmates to linger for days in hospitals waiting on routine procedures. But now that the bill is being paid, Singh said, his agency follows up to make sure that inmates are not being billed for days that they spend in hospitals when they could have spent only hours.

Medical improvements needed

While the financial help from DOC provides some relief for East Baton Rouge Parish officials, jail medical staff said they have a lot of work to do to improve care. Medical workers say they need more employees and better equipment if they are to effectively turn their workplace into a primary care clinic.

Simpson started her job as interim prison health care manager in September after spending most of her career working under the EMS umbrella.

She has already tried to revamp the way prison medical workers operate with re-training on payroll and leave policies.

But finding people to hire who can meet the requirements of the job is one of her biggest hurdles. Simpson recently received paperwork on three applicants for jobs as health care technicians — licensed practical nurses — at the prison. One did not pass a psychiatric exam, another did not pass the background check and the third could not pass the physical exam.

Simpson, a paramedic, remembers that EMS paramedics used to be able to work overtime shifts at the Parish Prison in 1990s. A rule change happened sometime afterward and the health care technicians are now required to be LPNs. But she said opening up job applications to paramedics again might be the key to finding more prospective hires.

“Correctional nursing is almost like a specialty, and not everybody can deal with this,” she said.

The job might appeal to older paramedics who no longer want to work on ambulances, which requires more physical exertion, Simpson said. She said paramedics and LPNs have skill sets that complement each other, as paramedics can put in IV lines whereas LPNs require special certifications to do so.

Another challenge for the prison’s medical workers is keeping up with the wide array of supplies needed for them to serve prisoners with many different medical problems.

A stockroom at the prison is piled from floor to ceiling with medical supplies including catheters, bandages, gloves, TB syringes, blood sugar sets, cotton balls, laceration trays, adult diapers, pregnancy tests and other supplies that inmates have needed at one point or another.

But because most of the inmates at the Parish Prison are pre-trial, it’s difficult to keep up with the needs of each inmate cycling through. Simpson said she may order enough bandages for five inmates with fresh amputations, but then the inmates could be released a few weeks later, leaving her with an abundance of supplies specific to a medical condition that no longer applies to any of her patients.

The crowded state of the stockroom was particularly disturbing to Metro Councilwoman Donna Collins-Lewis, who toured the prison medical facilities a few weeks ago. The city-parish commissioned a $95,000 study in October to determine the best path forward for the prison’s medical operations.

Collins-Lewis said the medical facility is too small and that it creates dangers for both the prisoners there and the staffers who work there. Both she and Daniel have reiterated the need for a new Parish Prison, saying the prison medical facilities are one area that could certainly improve.

Collins-Lewis encouraged others to tour the prison’s medical space.

“When you go up there, you’ll see what I’m so passionate about,” she said.