Corrections health chief cites rising medication costs, outlines tattoo-removal plan and treatment priorities

Dr. Stephanie Grama, Correctional Health Authority for the North Dakota Department of Corrections and Rehabilitation, told the Appropriations - Human Resources Division committee that rising medication and specialty-treatment costs and an aging incarcerated population are driving increases in the department's medical budget and described plans to partner with local clinics to provide tattoo removal for people in custody.

Grama said hepatitis C treatment and high-cost biologic and cancer medications are major drivers of spending. "We've actually decreased our incidence on admission of hepatitis C from 16.7 percent in 2018 down to about 11 and a half percent now," she said, describing progress from treatment efforts while warning that treatment costs upfront are large but avert higher costs from complications later.

She told committee members the department did not request tattoo-removal equipment for the current biennium because of equity and operational concerns: purchased equipment would be housed at the North Dakota State Penitentiary, an all-male facility, effectively excluding women from an in-house program. Instead, Grama said the department has begun discussions with a local clinic and would open the service to local providers through bids. "If that service had started prior to a person's release from incarceration, they would complete that service even after incarceration if it took more treatments than they were able to be offered during incarceration," she said.

Grama said a survey at one women's facility found over 80 percent of residents would be interested in tattoo removal, often for reasons beyond regret, including tattoos placed without consent or marking tied to trafficking or coercion. She described a proposed community-partner model in which a clinic would close regular business for a brief period each month to perform removals for up to six people at a time, offer fixed pricing by tattoo size rather than number of treatments and continue care after release if needed.

On costs, Grama told the committee the clinic she spoke with paid about $250,000 for a used, refurbished piece of tattoo-removal equipment. She added that the state would need to register, certify, maintain and eventually replace owned equipment, which influenced the decision to pursue a community-partner model.

Committee members pressed Grama on broader cost drivers. She said the department's incarcerated population is aging and sicker: nationwide the share of people in custody aged 55 or older rose from about 3 percent in 1991 to about 15 percent in 2021, and incarcerated people's bodies typically show health problems 10 years earlier than chronological age. That contributes to more patients needing expensive specialty care. Grama described individual cost examples, including a single patient receiving a medication that costs the state about $50,000 per year.

Grama described pharmacy purchasing strategies that limit spending where possible. She said the department uses the federal 340B program for discounted drug pricing and provided a recent example: "for the month of February, what our 340B pricing has saved us is $530,000," she said. Still, she said, new specialty medications that are not available under 340B pricing and inflationary manufacturer costs have pushed the department to request a $1.4 million increase in medication funding.

On treatment for opioid use disorder, Grama said the department provides long-acting injectable buprenorphine rather than sublingual films or tablets because of diversion risk and other concerns; the department delivers roughly 45 injections per month at a cost of about $63,000 per month, funded in part through opioid-settlement funds and the SOAR grant program. She cited research showing that medications for opioid use disorder at discharge reduce overdose deaths and lower recidivism.

Committee members and Colby Braun, director of the Department of Corrections and Rehabilitation, indicated the overview addressed the items they requested. Braun said the department had no additional items to add at this meeting and that the overview was complete for the topics asked to be revisited. Grama and department leaders said the next steps include pursuing bids and formal agreements with community providers for tattoo removal and continuing efforts on hepatitis C and other high-cost medical needs.

No formal votes or motions were recorded during this portion of the meeting.