Jacqueline Reich died after health care workers in a Nevada jail failed to treat her diabetes. Lorenzo Ingram Sr. was one of four Alabama prisoners to die after technicians put the wrong chemical in their kidney dialysis machine. Henry Simmons died of a heart attack in a Virginia prison when a doctor's orders for tests were ignored.
Correctional Medical Services Inc. of St. Louis would hope you never hear about these events.
That's because the inmates, and others like them, died in the care of CMS in prisons and jails across the country. The company has settled lawsuits with agreements that attempt to keep them secret.
CMS, headquartered on Olive Boulevard in west St. Louis County, is the nation's largest correctional health-care firm. The company provides health services to more than 268,000 inmates at 341 sites in 30 states, including Missouri and Illinois. In terms of revenue, it's three times bigger than its nearest competitor.
For nearly two decades, CMS and a few other managed care companies have been taking over prison and jail health care from government agencies coast to coast. For a fee, their workers provide everything from Band-Aids and Tylenol to heart-bypass surgery and psychiatric counseling.
They have become key players in the American system of justice.
There is reason to question the quality and motives behind much of today's correctional health care.
Taxpayers are paying billions of dollars to these firms. Missouri taxpayers alone have already paid CMS $154 million over the past six years.
The companies are increasingly on the front lines of public health. Prisons and jails are packed with criminals that the rest of society would just as soon forget -- largely a collection of murderers, thieves and other unsympathetic characters.
But inmates return to free society each year by the millions, carrying with them hepatitis, tuberculosis, mental illness, AIDS and a host of other health problems. And they come into contact with us in stores, ballparks, restaurants, airplanes and buses -- anywhere an American may go.
This managed care arrangement, industry and government officials say, saves the public money and improves health care for prisoners, especially when compared with the notoriously poor correctional health care of past decades.
But there is reason to question the quality and motives behind much of today's correctional health care.
"We save money because we skip the ambulance and bring them right to the morgue," quipped nurse Diane Jackson, one of those implicated in the death of an inmate at a Florida jail. Joke or not, Jackson summed up an attitude that is a dangerous reality now at play in the nation's prisons and jails.
More than 20 inmates allegedly died as a result of negligence, indifference, understaffing, inadequate training or overzealous cost-cutting.
That attitude was just one of the unsettling findings made by a Post-Dispatch investigative team that included a Chicago-based specialist in correctional health care.
The team spent more than five months visiting prisons and jails; gathering hundreds of police, court and medical records and other documents; and interviewing doctors, nurses, inmates, lawyers, scholars, prison and health experts and families of inmates who died behind bars.
What emerged was a picture of an industry that, at best, is still trying to find its way through the complex problems posed by health care in a prison environment. At worst, it was a picture of an industry that takes advantage of the public's ill will toward inmates to give poor care while making a profit.
The team found more than 20 cases in which inmates allegedly died as a result of negligence, indifference, understaffing, inadequate training or overzealous cost-cutting.
Inmates used to call government-run prison infirmaries "the butcher shop." These are yielding to "HMOs behind bars," as some in the industry call their programs, referring to free-world Health Maintenance Organizations that offer pre-paid medical services to subscribers.
An encounter with HMOs behind bars can quickly become a death sentence, even for inmates whose cases have not yet gone to trial or who have been convicted of relatively minor crimes. Many are young people, with treatable conditions. Consider:
Calvin Moore, 18, died in February 1996 after serving only a few weeks of a two-year burglary sentence in the Kilby Correctional Facility in Alabama. He lost more than 50 pounds in less than a month and suffered symptoms of severe mental illness, dehydration and starvation. CMS was responsible for his health care.
Diane Nelson, 46, mother of three, died of a heart attack in March 1994 in the Pinellas County Jail, in Florida, after three nurses with Prison Health Services Inc. ignored her repeated requests for heart medication prescribed by her doctor. Nelson had been arrested for slapping her teen-age daughter. As Nelson collapsed, a nurse yelled: "Stop the theatrics."
Charles Guffey, 39, died of a perforated ulcer October 1997 in the Tulsa County Adult Detention Center, in Oklahoma, after nurses working for Wexford Health Sources Inc. allegedly ignored his pleas about severe abdominal pain. Jailers said a nurse told them told them to return Guffey to his cell and "let inmate justice take its course." He had been booked into the jail after failing to appear in court on drug charges.
Nancy Blumenthal, 17, committed suicide in May 1996 in the Westchester County Jail, in Valhalla, N.Y., after a doctor working for EMSA Correctional Care took her off of an antidepressant drug following a 20-minute interview, even though she was suicidal. Blumenthal had been jailed for robbery and for threatening her mother with a kitchen knife.
These deaths hint at a broader system of "unusual punishments" proscribed by the Eighth Amendment of the Constitution. They point to an attitude that runs counter to the Hippocratic Oath, the creed of the medical profession, which says practitioners must keep "free from all intentional wrongdoing and harm" no matter where they work.
The Post-Dispatch also found that:
Some of the industry's leaders are putting inmate health care in the hands of doctors who have been disciplined by state medical licensing boards or even committed crimes themselves.
In some cases, a disciplined doctor who isn't allowed to practice on the general public permitted to do so behind bars -- even if he has lost his Drug Enforcement Administration license for prescribing controlled substances. That means he can't prescribe something as simple as Tylenol 3 for a toothache.
Distant administrators intervene in the practice of medicine by doctors, often second-guessing their decisions on economic grounds. The extra steps can delay treatment or approval for medication.
A culture of skepticism permeates correctional health care. Inmates fake illnesses, which can leave nurses and doctors blind to cases of real sickness.
The National Commission on Correctional Health Care, which sets standards and accredits prison and jail health care operations, does not serve as the watchdog that private companies claim.
Medical records are altered. Records have been changed to falsely indicate doctors gave medical orders when in fact a nurse did.
Medically questionable deaths behind bars aren't exclusive to jails and prisons with privatized care. For example, an inmate in the St. Louis Workhouse died in May from complications of asthma after treatment was delayed.
And in July, a U.S. district judge in St. Louis awarded $781,000 to the family of a Cape Girardeau man. He hanged himself in a federal prison in Georgia after public officials there withdrew his anti-anxiety medication, allegedly to save money.
Critics of the private companies say the industry's astounding growth and drive for profit raise extra cautionary flags.
"Appalling things are going on in some of these facilities in the name of efficiency, saving money and managed care," said Michael Vaughn, a professor of criminology at Georgia State University, in Atlanta. Vaughn grew up in Lebanon, Mo., and went to Central Missouri State University. He analyzes court cases involving prison and jail health care issues and serves as an associate editor of the scholarly journal, "Justice Quarterly."
For every death there are hundreds of inmates receiving substandard care.
"For every death there are hundreds of cases of inmates in these correctional facilities who are receiving substandard care," he said. "I've seen enough smoke to know that fires are definitely burning."
Michael Pfeiffer, CMS's chief operating officer, disagreed with those who say the deaths were the tip of an iceberg in a failing system.
"I don't believe that this is some underlying systemic problem," Pfeiffer said.
Of the criticism that the companies have to deny care to make a profit, Pfeiffer said: "That's crap. O.K.? Plain and simple. That's not true. You don't have to deny care to get a better deal from pharmaceuticals, negotiate with hospitals, do focus buying and do other kinds of things" related to economies of scale.
A threat to you
Dr. Thomas Conklin of the Hampden County Correctional Center, in Ludlow, Mass., knows that providing medical care to inmates is not a popular idea.
Diseases don't respect bars.
"After all," Conklin said, "many people say prisoners are scum -- why should we provide free medical care to criminals when our own children can't get free medical care?"
Inmates are not members of an isolated community -- they are inescapably part of the American community.
Simply put: diseases don't respect bars. Each year in the United States 12 million inmates return to free society, taking with them a broad range of diseases that are often infectious.
Without effective medical intervention in jails and prisons, released inmates "pose a threat to the public health of the community," said Edward Harrison, president of the National Commission on Correctional Health Care.
Poor health in inmates also threatens visitors, guards and other workers in prisons and jails. Inmate anger about health care has led to riots in some states.
The explosion of inmates has created a prison population bomb -- a growing body of older, sicker inmates whose increasingly serious health-care problems are likely to push costs even higher.
Adequate health care for inmates is guaranteed by the U.S. Constitution and mandated by the Hippocratic Oath.
If not well cared for in prison, a released inmate's health problems add cost to the nation's health-care tab.
A social problem
The changes in correctional health care are occurring against a backdrop of rising numbers of inmates in prisons and jails, longer sentences and escalating costs for health care.
When American voters decided two decades ago to get tough on crime, they began building the largest prison system in the world. In 1980, prisons and jails held about a half-million inmates. By 1998 that number had more than tripled, to 1.7 million.
Non-violent offenders accounted for much of the influx.
Prisons are home largely to the poor and uneducated and people with drug habits and broken families.
Many are in poor health and haven't seen a doctor since they received immunizations before entering kindergarten. In some respects, they are lucky to get the medical treatment, eye exams and dental care provided in a prison.
Roughly one in 10 of the inmate population today is mentally ill. Many of them ended up in prisons and jails when budget cuts closed state mental hospitals in the 1980s. In many cases, prison worsens a mentally ill person's condition by the time they return to the free world.
They become harmers instead of healers.
Some health-care workers have bought into a river of public anti-prisoner sentiment that simply putting an inmate in prison isn't sufficient punishment, Vaughn said.
"They turn the Hippocratic oath on its head," he said. "They become harmers instead of healers."
In an article to be published in 1999 in Justice Quarterly, Vaughn and Linda Smith, a researcher at Kennesaw State University, near Atlanta, identified six kinds of "ill-treatment and torture" recently inflicted at an unidentified county jail.
Among other examples, the researchers found evidence that nurses ignored the pregnancy problems of some inmates, withheld medications for AIDS, delayed treatment for hernias and abruptly took a Vietnam veteran off his psychiatric medicine to treat post-traumatic stress disorder -- a move that creates severe withdrawal.
A history of abuse
There's a long history of unusual punishment by medical personnel in prisons and jails across the United States.
After World War II, prisoners were used as "volunteers" in experiments on medical problems ranging from athlete's foot to radiation exposure.
After World War II, prisoners were used as "volunteers" in experiments on medical problems ranging from athlete's foot to radiation exposure. In 1956, researchers injected cancer cells into more than 100 inmates in Ohio to see how their bodies would respond.
In Arkansas, state prison doctors tolerated medieval torture and murder through the 1960s -- and in some cases became involved. A doctor at the Tucker State Prison Farm created the "Tucker telephone," an electric device strapped to the inmate's genitals to inflict pain short of passing out.
Arkansas prison doctors and state officials tried to conceal beating deaths by listing the causes of death as "malaria," "heart ailments" and "unknown."
In the 1970s, correctional health services improved as the American Medical Association developed standards for health care. Professional organizations set up training programs and other aids.
The case of a Texas inmate with back pain led to a 1976 Supreme Court decision known as "Estelle v. Gamble." The court agreed that the government had an obligation to provide "adequate medical care" to prisoners.
But the court set a high standard for prisoners to prove violations of that constitutional right. The judges said "deliberate indifference to serious medical needs of prisoners," if proven, constituted "the 'unwanton infliction of pain' proscribed by the Eighth Amendment."
The get-tough policy swelled the prison population in the 1980s.
"The sheer numbers strained resources, especially as shrinking public funding bases during the late 1980s and early 1990s limited staff increases and equipment purchases," said Dr. Kim Marie Thornburn, an expert in correctional health care with the Spokane Regional Health District. "Health care facilities in jails and prisons grew more cramped and inadequate."
The bottom line
Enter the prison HMOs.
Of the estimated $3.75 billion a year now spent on correctional health care, managed care companies account for upwards of 25 percent, say industry analysts. They put the industry's net profit margin at a scant 1 1/2 to 2 percent.
The companies say they offer many advantages over government-run correctional health agencies. They streamline the on-site health-care operation, cutting the need for visits to hospitals.
They have an available pool of doctors, nurses and other workers that can fill gaps in staffing more quickly than government bureaucracies. The private contract makes it easier for government officials to predict costs and concentrate on security.
A company can run health care between 5 and 15 percent more cheaply, depending on the prison or jail.
Correctional health-care companies "save hundreds of millions of taxpayer dollars at the state and local levels," Dr. Stuart Shapiro, president of Prison Health Services of New Castle, Del., testified before Congress.
Critics warn that the growth in privatized correctional health care is part of a burgeoning "prison industrial complex." That refers to a network of companies and their subsidiaries that manage private prisons and provide such services as health care, food and equipment.
For a company paid a fixed rate, every dollar not spent on health care is profit.
Among other issues raised by privatizing prison health care is whether the pursuit of profit -- a tradition as American as apple pie -- has led to dishonest practices. Government agencies have found that some companies exaggerate the amount of medical care they provide or leave positions unfilled.
Every dollar not spent on health care is profit.
In Massachusetts, for example, the state auditor in 1996 accused EMSA of overcharging the state $1.5 million by inflating the number of AIDS patients and the cost of their treatment. The company filed false and questionable invoices between January 1992 and June 1994, said auditor Joe DeNucci.
A spokesman for the company said it got the number of of inmates with AIDS from the Department of Corrections, "so there was no way possible we could inflate the number." The auditor stood by his report.
In Florida, in a 1995 contract with one of its doctors, EMSA offered a $250 bonus each time he eliminated an emergency-room visit for a jail inmate. Such incentives are given by a few companies, said B. Jaye Anno, an authority on correctional health care who objects to such incentives.
"This sets the stage for a potential conflict between what may be in the patients' best interest and what may be in the self-interest of the physician," Anno said.
In Illinois in July, the regional administrator for a national firm complained in a memo to the medical director of a state prison that he had gone over his monthly budget.
"I will not blindly approve an over-budgeted supply requisition simply because you need it," the administrator said. "...We are in severe financial difficulty at your facility and the pattern of spending more than we have allocated is what got us here. You must be more cost conscious than ever."
In Oklahoma, licensed practical nurse Sherry Burkybile said a Tulsa jail often went without basic medical supplies on the night shift. If nurses ran out of peroxide, "you used water. It don't work as good, but you improvised."
Bandages? "Ran out. There's nothing you can do. You put a paper towel on it... I ripped up a sheet and got in trouble because that was state property."
Burkybile's statements came in a December deposition about jail care and her former employer, Wexford. She explained the bureaucratic maze for sending an inmate to the emergency room.
If an inmate showed signs of a potential heart attack -- dizzy, chest pain, left arm hurting -- Burkybile had to be convinced the inmate wasn't faking. She didn't want to wake her supervisor at home over a false alarm.
She also had to get permission from the director of nursing or a jail administrator to call the doctor. Sometimes, as precious time elapsed, Burkybile had to page these people and wait for a reply. Only then could she call the sheriff's deputy to pick up the inmate.
"If I was lucky and I had a commander on that was good, he would call transport, and transport would come and get them, but it would take at least two hours," she said.
The medical staff cut costs wherever they could, she said. They would distribute expired medicine or keep an inmate's personal medicine on the shelf even after that inmate had left jail.
When a state inspector made a routine visit, the staff usually had a week's notice, she said. Staffers would box up the expired medicine and store it in an administrator's office until the inspector left.
Wexford declined to comment.
A patient in prison has no choice. And no consumer advocate.
For inmates, this bottom-line mentality, combined with the push to expand punishment beyond imprisonment, can lead to abuses.
In the free world, a sick person has choices -- even an HMO patient may be able to switch doctors or plans if unhappy.
A patient in prison has no choice. And no consumer advocate.
"If you think of every evil that exists in HMOs and multiply it by 10, you'll understand what happens with CMS," Richard Sindel, a Clayton lawyer who has battled the company on behalf of female inmates in Missouri. "Not only do they have a captive audience, literally and figuratively, they have one that has absolutely has no power at all."
Jacqueline Reich, Lorenzo Ingram and Henry Simmons -- and all the others, if they were alive today -- might be inclined to agree.
Check out the rest of this hard-hitting investigative series on the Post-Dispatch site.
Reprinted with permission. © St. Louis Post-Dispatch
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