Telemedicine averted about 35 trips for inmates to see local specialists outside prison walls, for a savings of approximately $27,500.

During the 11 months prior to telemedicine’s implementation, Lewisburg inmates were taken out of the prison 419 times to meet with local specialists, either in their offices or in a community hospital (called external consultations because they occurred outside the prison walls). There were also 119 external consultations for USP-Allenwood inmates and 160 for FCI-Allenwood inmates.⁵ With this volume of external consultations, each of which requires extensive and costly security measures, one hope for the demonstration was that fewer inmates would need to be taken outside the prison to see local specialists after telemedical capabilities became available.

At the end of each telemedicine consultation, prison staff were asked what would have happened had telemedicine not been available. In most cases, staff reported that the inmate would have eventually seen a visiting specialist; in a few cases, either an external consultation or a transfer to FMC was thought to have been avoided. Whenever it was suggested that one of these costly events was avoided, the health services administrator for the prison was asked to review the case and verify that an external consultation (or a transfer) would have occurred without the telemedicine session. Prison staff identified a total of 35 external consultations that were avoided by using the telemedicine system, all among inmates of USP-Lewisburg.⁶

The savings produced by avoiding such external consultations was calculated by identifying a set of comparable external consultations during the 11 months before the demonstration period that could reasonably have been attempted with telemedicine and by pricing the various components of these events (see appendixes A and C for discussions of these data). The average cost of external consultations during this period is estimated at $788.⁷ This figure included medical care expenses averaging $320, administrative expenses averaging $197, and security/escort costs averaging $271 per consultation. In summary, for the 35 avoided external consultations, the total savings during the entire demonstration period is estimated to be $27,580.

Why were so few of these costly consultations replaced by telemedical ones? To explore the reasons for this, the research team discussed lists of all external consultations with prison clinical staff and learned that the majority of them were for care that cannot be provided remotely. Emergency and trauma care, surgery, invasive tests and procedures, or care requiring special (nonmobile) equipment all necessitate transporting inmates outside the prison to specialists in hospital outpatient departments or in their own offices. USP-Lewisburg had the most external consultations and, hence, the most opportunity to reduce them. Telemedicine did not avert any external consultations at either of the Allenwood facilities, in the opinion of the health service administrators at those two prisons. Had the mix of prisoners or the decision rules been different, the number of external consultations and their distribution among the prisons might have differed from what was observed. These events therefore introduce an element of uncertainty into cost calculations.

⁵ Because FMC-Lexington used telemedicine in only a few specialties for which it otherwise would never approve external visits to specialists (e.g., podiatry), reductions in these external visits were not expected or sought.

⁶ The frequency of external consultations experienced at the three Pennsylvania prisons was higher during the demonstration period than during the 11 months prior to telemedicine’s implementation. These differences reflect normal variation in numbers of cases requiring trips to hospitals or to specialists based there and should not be attributed to any effect of telemedicine on the utilization of these external resources. Furthermore, the rates of using consulting specialists prior to the implementation of telemedicine cannot be viewed as characterizing "normal" or "appropriate" levels of demand. For example, the penitentiaries were "locked down" for some periods of time; contracts with consulting physicians were not in force for part of the year; and primary care staff may have chosen to treat patients they would have otherwise preferred to send to specialists.

⁷ This calculation does not recognize some "hidden" costs associated with external consultations, such as additional staff time and the use of government vehicles and equipment for medical trips. In addition to the staff listed in the appendix tables, each trip involves unit clerical staff and receiving and discharge staff. The analysis also leaves out costs associated with the vehicles, including specialized handicap-equipped vehicles with motorized chair lifts. Considering these costs would slightly increase the advantage of telemedicine.