In September, 1996, Melody Bird complained to guards at Florida's Pinellas County Jail that she was experiencing severe chest pains and having trouble breathing. Nurses at the jail, finding no discernible blood pressure, concluded that Bird was suffering a heart attack.
An immediate call for an ambulance to transport Bird to a hospital emergency room would likely have saved the prisoner's life. Instead of calling 911, though, the nurses called the medical director of Emergency Medical Services Associates (EMSA).
Pinellas County had contracted with the private company to provide health care services to its county jail inmates. EMSA's procedures did not allow for its employees at the jail to send a prisoner to an outside hospital without prior approval from a company bureaucrat.
Thirteen hours after the nurses first contacted EMSA's medical director, they received permission to call an ambulance. But Melody Bird couldn't wait that long. Her pulse stopped before she reached the emergency room.
Bird, a 24-year-old jailed on prostitution charges, had a history of serious heart problems. Nonetheless, EMSA medical staff at the jail took her off previously prescribed heart medication.
The contract between Pinellas County and EMSA is similar to managed care arrangements that are common outside of prison. The county paid EMSA a fixed amount to provide all health care services for prisoners at the jail over a specified period of time. The fewer services and medications EMSA could get away with providing, the greater its profits would be under the contract.
Critics of managed care have raised questions about the profit incentives created by this type of contract, and the Melody Bird case adds plenty of cause for concern. In the investigation subsequent to Bird's death, several EMSA nurses came forward to say the company pressured them to keep prisoners away from outside hospitals. Everett Rice, the sheriff of Pinellas County, says he discovered after the Melody Bird ordeal that EMSA had previously paid the company's medical director $250 bonuses for denying requests for emergency-room treatment.
Twenty years ago, almost all prison inmates were young men. Since then, the movement toward mandatory minimum sentences and greater awareness of sexual crimes against children have brought older, less healthy inmates into the prisons. New Jersey's prison medical expenses rose 500% between 1986 and 1996. Vermont reports a 412% increase over the same period.
As states and counties across the nation struggle to keep up with skyrocketing costs for prison medical services, managed-care arrangements can appear to promise an easy answer. EMSA has contracts to provide medical services for 26 prisons in 12 states. Correctional Medical Services (CMS), the largest company in the prison-medical-care business, has contracts with jails and prisons in 28 states.
In April, 1996, New Jersey Governor Christine Whitman dismissed the doctors and nurses who worked at the state's prisons and contracted with CMS to provide medical services to New Jersey's 26,000 state prisoners. Dr. Fred Bauer, who was in charge of health care at a New Jersey prison for eleven years, lost his state job when CMS took over. The company rehired Bauer for his old job, but he resigned after seven weeks, convinced that the managed-care system was depriving prisoners of needed health services.
Democratic state senator Wynona Lipman has harshly criticized New Jersey's contract with CMS, saying the company has been cited for systematic deficiencies linked to prisoner deaths in at least three other states. At the City Jail in Norfolk, Virginia, a 28-year-old man detained for a marijuana charge died after not receiving needed dialysis treatment because, according to the jail's investigations, a CMS medical assistant simply forgot to schedule the dialysis. Norfolk withdrew from its contract with CMS because of that incident. "I just can't believe the state of New Jersey is getting stuck with these guys," said George Schaefer, spokesman for the Norfolk City Jail. "I can't imagine anybody hiring them, not from the records we've seen."
As more states and counties contract with private companies for medical services, the horror stories continue to mount. For $300 million, a company called Prison Health Services (PHS) agreed to provide medical services in all Georgia's state prisons for six years. Within one month of the contract's effective date, state officials determined that PHS had failed to sufficiently staff the medical units at six prisons. The state fined PHS $260,000 for the understaffing at two facilities and threatened to fine the company $10,000 per day unless understaffing at four other prisons was corrected.
The Georgia example points up one particular dilemma inherent in private contracting. PHS waged a bidding war with the earlier mentioned CMS for the Georgia contract. PHS eventually underbid CMS by $4.6 million. After making the low bid, though, PHS apparently felt it didn't have enough money to hire adequate staff.
In Westchester County, New York, where officials contracted with EMSA for medical services, a 17-year-old girl committed suicide in the county jail after being denied previously prescribed anti-depressant medication. The part-time psychiatrist who treated the girl, 75 year old Dr. Harvey Lothringer, was hired out of retirement by EMSA. Lothringer himself served time on a manslaughter conviction. He fled the country in 1962 after dismembering the body of a woman who died during an illegal abortion he performed in New York.
In New Jersey, CMS hired unlicensed psychologists to treat prisoners with mental-health needs. Making recommendations to the state's parole board regarding prisoners' suitibility for release is one of the duties those psychologists perform. "It's not right to have people treating and making these decisions who are not fully qualified," says Carolyn Wade, president of the trade union local representing the nurses and other workers who were laid off when New Jersey contracted with CMS.
It's true that concerns about private companies denying medical services in order to increase profits are common to HMO arrangements outside prison as well. But HMO abuses in the real world have already raised the ire of Congress and state legislatures. In prison, it's hard for the public to even find out how health care is being administered. And few outside the walls, including legislators, show much concern over the treatment of prisoners. So the danger of private companies unduly denying medical services can be far greater in the prison context.
Of course, prisoners have often complained that the medical services provided by state employees also leave room for improvement. But the incentive to deny medical care just isn't the same for public agencies. "If the state legislature decides to cut the budget for prison doctors," says John Kettenbiel, serving time in Wisconsin for drug charges, "the Senators don't get to stick the money in their pockets."
The New York Times, The Camden Times, Today's Sunbeam (New Jersey), The Star-Ledger (New Jersey), The Times-Argus (Vermont)
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