by Michael Rigby

A Maryland prison is no place to get sick. Virtually every facet of prisoner health care, which has been provided by Tennessee-based Prison Health Services (PHS) since 2000, is in disarray. Prisoners sometimes receive the wrong medicine or none at all; records are poorly kept; physical exams are often cursory; sick call requests are ignored; and short-staffing is ubiquitous.

To address the problems, the Department of Public Safety and Correctional Services (DPSCS), which operates Maryland prisons and Baltimore jails has implemented a new health care system and changed providers. The department also promised to spend more money for health services. Some critics doubt the new system and additional money will make a difference since the quality of care--or lack thereof--will still be influenced by profit motives.

Medication mix-ups, and delays are common in Maryland prisons, according to independent audits, internal documents, and prisoner complaints. In a December 2004 letter to a concerned community organization, DPSCS Secretary Mary Ann Saar acknowledged the problem when she wrote, We have repeatedly heard complaints relating to the failure of inmates to receive medications ... in a timely manner." The situation can be deadly for prisoners with life-threatening illnesses such as asthma, diabetes, and AIDS.

Poor record keeping has exacerbated the problem. When state auditors
visited the infirmary at the Maryland House of Correction in March 2000, for instance, it was observed that one inmate had been in a bed on the unit for more than 15 hours. There was no admission order, transfer note, vital signs, history, initial nursing assessment, documentation of nursing protocols, or any treatment/care plan. Interviews with the nursing staff on the unit revealed that there was no information on the inmate.

Even when records are kept, they're not reliable. In March 2005, DPSCS officials discovered that PHS employees had apparently altered records at the Baltimore Women's Detention Center to indicate they had performed required checks of suicidal prisoners every 15 minutes. PHS officials said the employees involved resigned.

PHS medical personnel also regularly fail to perform sufficiently detailed examinations or follow up on prisoner complaints. In 2001, for example, Ricky Scearce, 48, reported all the classic signs of colon cancer to a prison doctor, according to his lawsuit against PHS. Though his symptoms persisted, it was two years before a colonoscopy was scheduled. The test revealed advanced-stage, terminal colo-rectal cancer. PHS settled with Scearce for an undisclosed sum in 2004.

Insufficient staffing is also a major concern. Audits of prison infirmaries performed by the independent Office of Health Care Quality found that staff shortages have caused long delays in prisoners being seen by doctors, nurses, and psychiatrists. At two Baltimore jails, the city detention center and the Booking and Intake Center, psychiatrists were available for only 100 of the required 156 hours each week in 2004. During this time, the jails had five prisoner suicides--the highest in seven years.

PHS blames the problems on the prisoners themselves. The company tries to have outcomes that are appropriate and desirable ... but it's a difficult environment and it's a difficult group of patients," said Richard D. Wright, president and chief executive of PHS until March 31, 2005. Wright noted that prisoners are usually sicker than the general population and that many have combined problems such as substance abuse, infectious disease, and chronic illness. Still, Wright's sentiment rings hollow considering that prisoners are the company's bread and butter.

PHS's Maryland contract expired on June 30, 2005. The company claims it tried to get out of the contract in 2003 because it was losing money, but the state refused. Over the life of its 5-year contract, PHS was paid $53 million annually to provide comprehensive health care to 24,000 prisoners across Maryland, except for three prisons in Hagerstown. During the same period, the company claims it lost $14 million.

Much of the problem, according to PHS, stems from the way its contract was structured. The company was paid a flat fee to provide a broad array of services, including medical, dental, and mental health care, and pharmaceuticals. Soon after it signed the contract, the company contends, medical costs soared as the price of hospitalization nearly doubled and expensive new AIDS drugs hit the market.

For the state, however, the contract was a good deal, essentially locking in costs. In fact, one of the few detailed analyses conducted by the state revealed that Maryland was spending $2,293 per prisoner on health care in 2002, well below the national average of $2,722. Consequently, when the issue of renewing PHS's contract came up in early 2003, state budget analysts urged Secretary Saar to extend the contract by two years because the state was paying far less than the cost of providing the services.
Some say the state should not have shirked its responsibility.
Dr. Ronald Shansky, an expert on prison health care, said states are obligated to provide an appropriate level of health care services to prisoners in their custody. If a contract is under funded, and not just poorly managed, that's also a state responsibility," he said. They should know what it takes per capita to provide the services .... and shouldn't support any bidder whose proposal is too low" to do the job properly.
In some cases, the deplorable conditions in which prisoners are held contributes to health care problems. Baltimore's jails are illustrative. The consistently overcrowded Booking and Intake Center and the adjacent city detention center have been criticized for their squalid living conditions. The jails are infested with vermin and cockroaches; sewage backups periodically flood the floors; and antiquated cooling and heating systems keep the jails freezing in the winter and sweltering in the summer.
The situation is no better at the Baltimore Women's Detention Center, where investigators with the Office of Health Care Quality visited the mental health unit in January 23, 2004. Inmates were found to tear apart the mattresses and climb inside of them to stay warm, and/or use some of the fiberfill material from the mattresses to cover the windows in an unsuccessful attempt to block out the cold air drafts from the outside," auditor's wrote. The women were climbing inside the mattresses because they were being held naked in icy cells. They were supposed to be given suicide smocks, said Dr. Annette Hanson, PHS's chief psychiatrist in Baltimore, but the smocks were often lost when they were laundered.

The jails' dilapidated conditions and PHS's poor health care stressed the relationship between prison officials and the company. In a May 2004 e-mail to a state prison official, assistant commissioner for the Division of Pretrial Detention and Services, Benjamin Brown, complained of ongoing conflicts with PHS over staffing and procedures for evaluating new jail arrivals. Their cavalier attitude to their contractual and ethical responsibilities is unacceptable; their inability or unwillingness to communicate effectively is equally unacceptable," Brown wrote.

In one case, PHS's failure to treat a female prisoner at the women's detention center ended in her death. Deborah Epifanio, 34, died on September 14, 2005, from an advanced case of cryptococcal meningitis. Epifanio had experienced fainting spells for days before PHS personnel sent her to the emergency room. PHS subsequently reprimanded and reassigned four employees for failing to properly perform their duties, but no one was fired .

The DPSCS has now restructured its health care system and hired other contractors to take over. The state estimates it will spend $110 million for prisoner health care services in fiscal year 2005-06, a 60% increase over the $68 million it spent the previous fiscal year.
But the very development of the new system has caused controversy. In September 2004, the state hired PHS co-founder Jacqueline Moore of Jacqueline Moore and Associates to write the parameters for the new contract. Moore, who started PHS in 1978 with her then-husband, claims there is no conflict because she has not been affiliated with the company since 1990. Critics, however, remain skeptical.

The new plan, which took effect July 1, 2005, divides prisoner health care into different categories and uses multiple private contractors. Despite its supposed bad experience in Maryland, PHS submitted a bid for the medical service component, the largest contract. That contract was ultimately awarded to PHS's main rival, St. Louis-based Correctional Medical Services (CMS). CMS has been the health care provider for the three prisons in Hagerstown since 2000.

The new system eliminates the flat-fee contracts. Instead, contractors will be reimbursed for certain expenses such as hospital stays. Pittsburgh-based Wexford Health Sources, another for-profit company, was picked to oversee and manage the use of hospitalization, said Richard Rosenblatt, who oversees medical care for the DPSCS. The contract provides Wexford financial incentives to keep costs down. The more they can hold down costs, the more money they make," Rosenblatt said. The new system will ostensibly incorporate quality control measures and greater accountability for sick call services, and will treat prisoners infected with hepatitis C.
Prisoner advocates are not convinced the new system will solve the problems as the state contends. A better option, they say, would be for the state or a nonprofit teaching hospital or other nonprofit organization to handle prisoner health care. As with other for-profit prison health care providers, PHS, CMS, and Wexford have sordid histories of patient neglect, haphazard care, and watered-down standards. And why wouldn't they? It's a simple equation, after all: less treatment equals more profit.

Take the tragic case of Marcella N. Leski, 39. In March 2002, Leski was jailed in the Baltimore Women's Detention Center for failing to appear in court on a drug-possession charge. Twelve days later, her legs had to be amputated below the knees. PHS doctors had failed to diagnose an infection that is easily treatable with antibiotics. Her brother, John Leski, said the lack of treatment was inexcusable. Any decent human being would say, Get her checked out,'" he said.

Leski's family has filed a lawsuit alleging doctors failed to perform a medical test that could have detected the infection. The suit also contends that Leski was deemed to be a malingerer" and given only over-the-counter pain medication, even though she could hardly walk and was in excruciating pain. The charges against her were eventually dropped as her health deteriorated. Several months later, Leski contracted a staph infection and died.

PLN reports extensively on prison health care issues, including privatization. See indexes for more.

Sources: Baltimore Sun, citypaper.com