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Dying For Profits: CMS and the Privatization of Prisoner Health Care

By Ronald Young

Marvin Johnson, a 28-years-old diabetic, required 100 units of insulin per day to stay alive. On the morning of July 27, 1995, he was arrested and jailed in Little Rock, Arkansas for driving an acquaintance's red Ford Escort without permission. Less than three days later, Johnson lapsed into a coma in his jail cell and died for lack of insulin.

Johnson was charged with misdemeanor unlawful use of a vehicle but ended up being sentenced to death. What was criminal in Johnson's case was the tortured death he suffered as a result of the blatant disregard to his pleas for help by the jail's medical provider Correctional Medical Services (CMS), based in St. Louis, Missouri. Johnson died on July 29, 1995, early in the morning of his third day in the Pulaski County Jail. In his 30-hour wait for insulin, Johnson told three nurses and six sheriff's deputies that he was an insulin-dependent diabetic and needed medicine, according to an investigative report reviewed by the St. Louis Post-Dispatch.

Despite his pleas for help, CMS staff denied Johnson his life-sustaining shots, claiming that they could not confirm his prescription because Johnson was vague about his medical history. This was in spite of the fact that Johnson's girlfriend, LaJeanna Hawkins, had called the jail's satellite holding area to tell them Johnson was diabetic. Hawkins even offered to bring insulin to the jail, but the deputies told her Johnson would be well cared for.

The nursing supervisor reportedly accused Johnson of "faking" his condition. "He was not forthcoming about his medical history, and he exhibited behavior that he was faking," David Fuqua, a lawyer for Pulaski County, told the Post-Dispatch. "They get a lot of that from inmates," he said. Susan B. Adams, CMS's director of marketing and communications, claimed in a 1996 written rebuttal to a New Jersey newspaper's investigation of the incident, "We were not informed of a call to the jail by Johnson's girlfriend."

"This gentleman had his diabetes ignored, to let it go 30 hours, even after he got sick, he wasn't evaluated for hours after that," said Dr. Neil White, an associate professor at Washington State School of medicine and vice president of the St. Louis region's American Diabetes Association. "It's clearly negligence," he said. "This is not even the appropriate minimum level of care. If they had started monitoring when he first came in ... he'd probably be alive today."

Annie Johnson, who helped her late sister raise Johnson and his three siblings, sued the sheriff and CMS, alleging medical malpractice, negligence and wrongful death. By November 1997, Pulaski County and CMS paid Johnson's family a settlement. Pulaski County's portion was about $20,000, Fuqua said. CMS, which demanded a confidentiality agreement, won't say how much it paid Johnson's family.

This is just one sordid chapter in a litany of abuses and deaths suffered by prisoners nationwide at the hands of CMS, the largest private health care provider to jails and prisons in the country. The Detroit News reported in June 2000 that CMS contracts with physicians and health care workers who serve more than 260,000 prisoners at roughly 315 prisons and jails in 27 states. It runs statewide prison health care systems in Alabama, Arkansas, Idaho, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New Mexico and Wyoming. CMS controls approximately 45 percent of the over-$1 billion market.

In November 1994, CMS hired Gail R. Williams, MD, to direct mental health services in Alabama prisons, even though Oklahoma had revoked his license to practice the year before for sexually battering and harassing a nurse and other female staff members. CMS helped persuade Alabama's Medical Licensure Commission to give Williams a license restricted to practice in prisons. CMS was fully aware of William's past mistakes and discussed them with the board of examiners, CMS's Adams told the Journal Of the American Medical Association (JAMA). "We are confident that we have measures in place to prevent him from repeating his past mistakes," she said.

Apparently these measures weren't enough to prevent Williams from making "new" mistakes concerning prisoner mental health services. A wrongful death suit was filed against Williams, CMS, and other CMS health care providers after the February 21, 1996 death of Alabama state prisoner Calvin Moore. Moore, 18, died in an isolation cell after serving only seven weeks of a two-year sentence in the Kilby Correctional Facility, a few miles east of Montgomery. According to JAMA, prison records show that, shortly after being admitted to Kilby on January 3, 1996, Moore began to display severe psychiatric symptoms. He stopped eating and, although he lost 56 pounds (over one-third of his body weight), he received no medical treatment other than one injection of the anti-psychotic agent haloperidol.

When Williams took charge for CMS of the mental health services in Alabama's prisons, he ordered the medical staff to greatly reduce the number of prisoners who receive psychotropic medications. He also discontinued the policy of sending the most severely mentally ill prisoners to Taylor Hardin, the state's secure medical facility. Instead they had to be treated within their respective prisons despite a shortage or absence of acute psychiatric beds and staff in the state's twelve prisons. Moore's isolation cell in the P-1 unit of Kilby was an austere administrative segregation cell not intended to house severely mentally ill prisoners. Critics of the Alabama prison system say the P-1 unit and others like it around the state also serve as warehouses for an overflow of mentally ill prisoners.

Moore spent the last several days of his life in the P-1 isolation cell sitting or lying in his own urine, most of the time in a catatonic state. For more than a week, until a few hours before his death, no one even bothered to take his vital signs. An official state report said Moore died of natural causes "possibly related to an unidentifiable heart lesion." However, Robert H. Kirschner, MD, senior forensic consultant to Physicians for Human Rights, who served as an expert witness in the case, called the report a "whitewash" and said Moore's death was a homicide caused by dehydration and starvation resulting from criminal negligence.

CMS settled the Moore lawsuit without an admission of wrongdoing for an undisclosed amount on August 31, 1998. According to spokeswoman Adams, the CMS staff at Kilby provided Moore with "appropriate and compassionate care." "The settlement was for the compromise of a doubtful and disputed claim," she said. "A consideration in CMS's decision to settle this case was the anticipated high cost of trial and the healthcare provider's time and attention would be diverted from their duties."

Williams isn't the only CMS-employed physician working in Alabama's prisons with dubious credentials. Walter F. Mauney, MD, who was the medical director at Kilby when Moore died, was also named in the Moore wrongful death lawsuit. According to CMS records reviewed by JAMA, Mauney was hired in 1995 shortly after being released from a drug addiction treatment center. It was also discovered that in 1979, a Monroe County, Tennessee grand jury charged Mauney with three counts of having oral sex with and sexually penetrating a 16-year-old "mentally defective" boy. Mauney, who was 40 at the time, pleaded guilty to one count of "crime against nature" and was sentenced to ten years in the state penitentiary, but the sentence was suspended.

Louis Tripoli, MD, CMS's chief medical officer, defended the company's hiring of Mauney. "Given Dr. Mauney's remorse, his desire to make amends, and based upon a review of his professional credentials and record available to us at the time, CMS believed that Dr. Mauney was a satisfactory candidate to provide inmate healthcare services," he told JAMA.

These hiring practices of CMS are part of an overall policy on the part of some states to issue medical licenses to previously revoked physicians, restricting their practice of medicine to prisoners. Sidney M. Wolfe, MD, director of Public Citizen's Health Research Group in Washington, DC, believes the public should be very concerned about such policies. "It is unethical and inhumane to say that a physician isn't trustworthy or good enough to treat people in the community, but that he or she is good enough to care for inmates of correctional facilities or mental hospitals," he told JAMA.

The Norfolk City Jail in New Jersey severed its contract with CMS in 1994, after the deaths of seven prisoners between 1993 and 1994, many because of medical reasons, jail officials reported. Norfolk Sheriff Robert McCabe said publicly in 1996 that his jail's health care was in a state of crisis. The U.S. Justice Department investigated CMS's Norfolk operation and concluded that the company's medical services there were "grossly deficient and violated inmate's constitutional rights."

In a written rebuttal on behalf of CMS, spokeswoman Adams stated to the Gloucester County (NJ) Times: "At Norfolk, CMS was unfairly blamed for the problems of the jail, which were actually symptoms of much larger and more chronic issues such as inadequate funding for jail services, an antiquated facility and extreme overcrowding." In the meantime, a suit filed by one of the deceased prisoner's families was settled out of court by CMS. In that case, Jerome J. Walton, Jr., 28, arrested on probation violations and a marijuana charge, died when a CMS medical assistant at Norfolk simply forgot to schedule him for a much-needed dialysis treatment.

In spite of Norfolk, the State of New Jersey awarded CMS a three-year, $187.2 million contract in 1996, to provide health care services to the state's approximately 26,000 prisoners in state prisons. The body count began almost immediately. The first death occurred only three days after CMS took charge. April 1996, when John Orriello, serving ten years for burglary, stopped breathing and died after a succession of oxygen tank failures. CMS blamed a defective regulator it had inherited from the state. Still, within less than a month her taking charge, four prisoners had died due to problems with the health care delivery system provided by CMS.

CMS currently has a three-year contract with New Jersey for $90 million-a -year employing some 1,200 doctors, nurses, technicians and health aides in the state's prison system. The contract expires in 2002.

On June 14,1999, Hatari Wahaki, 41, a prisoner at the New Jersey State Prison, wrote a letter to the American Friends Service Committee complaining of searing temperatures in the ad-seg wing of the over-100-year-old prison and lack of medical for prisoners medical care that was suppose to be delivered by CMS. "I have been trying to get medical attention for months regarding a chronic respiratory condition whereas my lungs are rapidly deteriorating," Wahaki wrote. "I constantly have severe headaches where it feels like the flow of oxygen is being cut off from my brain causing sudden surges of pressure that be so intense it knocks me off balance. I have been experiencing these symptoms for over a year, yet the medical department steadfastly refused to treat me," he said.

Wahaki, along with prisoner Vidal Prince, 48, was found dead on July 4, 1999, in a cellblock described as a "brick oven." Authorities claimed that both men died of "natural causes" and not from the extreme heat or lack of medical care.

CMS makes much of its capacity to win accreditation for contracted facilities from the National Commission on Correctional Healthcare (NCCHC). But B. Jaye Anno, a doctorate-level expert in prison health care and a co-founder of the NCCHC, explained to the Garden State News Service that the accrediting organization focuses more on whether a facility has the "infrastructure" to deliver proper health care, not whether the facility does in practice deliver that care. "It's fair to say they look at minimum standards," Anno said.

CMS's Adams pointed out that CMS was able to obtain accreditation through the NCCHC for both the Norfolk, NJ and Pulaski County, AR jails. Yet, at least in the case of the Norfolk lockup, Adams put partial blame for prisoners' deaths on an "antiquated facility." In light of Anno's statement that NCCHC accreditation focuses mainly on a facility's infrastructure, it would appear that Adam's attempt to shift the blame from CMS to inferior facilities must be looked upon with a suspicious eye. NCCHC certification shows that the necessary minimum medical infrastructure was in place at Norfolk. If it can be shown otherwise, as Adams originally maintained, then this would prove that NCCHC certification is basically meaningless. Whichever may be the case, this bit of contradiction shows that CMS is being purposely evasive and even misleading as to what of who actually caused the deaths at Norfolk.

Lawyers for the State of New Jersey and CMS appeared in federal court on July 17, 2000 to fight efforts by New York-based Human Rights Watch (HRW) to have access to progress reports about psychiatric treatment being provided to mentally ill state prisoners. Bruce Cohen, a Chathan, NJ lawyer handling the case for HRW, told the Associated Press that the broad secrecy imposed by the state and by CMS was disturbing. "The public of New Jersey doesn't realize that the situation in New Jersey prisons for the mentally ill was horrendous," Cohen said.

The Center for Social Justice, a public-interest group based at Seton Hall University law school, filed a class-action lawsuit on behalf of mentally ill prisoners in New Jersey that was settled in a confidential agreement (CMS's favorite form of settlement) in July 1999. CMS argued that required follow-up reports on conditions are also confidential under the settlement. Jamie Fellner, a staff attorney for HRW, said she was disturbed by the secrecy attitude conveyed by the attorneys representing the private firms. "It would be a disaster for democracy, and certainly for the criminal justice system, if the fact that you privatize suddenly means the public cannot know how its responsibilities and the state's responsibilities are being met, and yet that would seem to be the argument that the subcontractors would like to make," she told the AP.

CMS spokesman Ken Fields said Fellner was incorrect. "We welcome any independent examination of the health care services we provide," he told AP. "The fact that CMS is a private company has nothing to do with the fast that those monitoring reports were confidential."

In Michigan, United Auto Workers (UAW) Local 6000 filed a suit on May 25, 2000 in federal court seeking a temporary restraining order to keep the state from replacing approximately 70 prison health care workers with CMS employees. Since February 1998, Michigan has had a $37 million-a-year contract with CMS to cover off-site hospitalization and specialty care for the state's approximately 45,000 prisoners. The latest expansion of the contract, which the UAW suit is over, includes CMS providing on-site primary care, becoming in essence the gatekeeper making the determination of which prisoners will receive off-site services. The potential for abuse by CMS in order to cut costs is obvious. These additional services will cost Michigan taxpayers an additional $9 million a year.

Without the remedy, the UAW lawsuit says, CMS as the nation's largest supplier of medical care to prisons would expose state prisoners to "the so-called care of a company whose track record shows a profound and continuing defiance of constitutional standards of care."

The UAW suit points to a North Carolina case where CMS is facing an involuntary manslaughter charge for the 1996 death of prisoner Clarence Junior Cousins. Cousins, 37, a textile worker, was put into a special medical-watch cell at the Forsyth County Jail, where CMS provides prisoner health care services. An autopsy showed that Cousins died from alcohol withdrawal.

Prosecutors allege that Cousins' alcohol withdrawal went untreated after a CMS nurse, Arthelia Moser, who was untrained in alcohol withdrawal, misdiagnosed Cousins as having a mental disorder. Moser was indicted in October 1998 for involuntary manslaughter. Cousins had told a nurse when he was admitted into the jail that he had been drinking heavily. The indictment against Moser said that a person exercising ordinary care or reasonable caution would have seen that Cousins needed treatment and that Moser's inaction contributed to Cousins' death.

Sheila Cousins, Cousins' wife, and his children fied a civil suit in March 1997 against Moser and CMS. Both settled the lawsuit out of court in March 1998 for $175,000.

In response to the involuntary manslaughter charge against CMS, spokesman Fields told The Detroit News, "The allegations are false." He said the allegations concern staffing levels and pointed out that staffing levels at the time exceeded required levels. He also said CMS still operates at the Forsyth County Jail.

The UAW suit also cites an opinion from an Idaho judge who in May 2000, cited scandalously poor treatment in the states prison health care system (operated by CMS)and ordered the release on probation of an ailing, elderly man he sentenced November 1999 to up to six years in prison for vehicular manslaughter.

In ordering the release of the prisoner, Kenneth L. Pool, Fifth District State Judge Monte Carlson commented on the level of health care being provided by CMS, stating: "Mr. Pool deserves to be punished and he deserves to be in prison. His sentence is well within the punishment authority given to district court judges, and in my opinion is appropriate. But his treatment in the first five months of custody in the Idaho State Prison more closely resembles physical torture than incarceration. His treatment violates the standards of decency in today's society."

Judge Carlson also said that a private physician who examined Pool concluded that a doctor providing such medical care to a patient outside prison would be guilty of malpractice. Idaho DOC spokesman Mark Carnopis defended CMS. "We've contracted with Correctional Medical Services ... to provide our medical care since October 1996," he told the AP. "They've done a very good job in providing that care and we're happy with them providing that care."

In South Carolina, state officials there weren't singing praises to CMS after having contracted with the company for nearly three years to provide health care services in 10 of the state's 32 prisons. That contract was terminated in January 2000. A report released in May 2000 by the South Carolina Legislative Audit Council found $632,698 in overpayments to CMS for providing HIV treatment to prisoners. The report also said that there was a severe lack of oversight by the state of CMS operations. In particular, it found that prison officials were lax in monitoring CMS prisons and fining CMS for violations, while CMS failed to meet standards for distributing medications to mentally ill prisoners at the Lee Correctional Institution. Prisoner counseling staff at both CMS and South Carolina Department of Corrections (SCDC) sites did not meet the minimum qualifications for their positions.

In prisons where the SCDC provided health care services, the report found only one of 40 required medical audits was conducted during the two years ending in June 1999. Likewise, none of the 21 required dental audits were conducted during the same two-year period. The report said that absent the necessary audits, it's impossible to determine what level of service is being provided.

The South Carolina report underscores the fact that the health care services provided to prisoners by the state, even in the absence of privatization, is often far from adequate. Often times the bad health care services of the state are made even worse when private contractors take control. The addition of a profit incentive exacerbates the already abysmal medical care given to prisoners.

A 1999 survey by the University of Massachusetts and Local 285 of the Service Employees International Union (SEIU) accused CMS of "buffing up" in anticipation of state audits and failure to adequately address staff shortages, among other things. CMS runs the statewide prison health care system in Massachusetts. The survey also indicated that some employees work without adequate medical supplies and are asked to sign off as having received training that they did not actually receive. 98 percent of the survey respondents said they work short-staffed, and 88 percent said they work without essential supplies. Only 19 percent reported that their facility had enough staff on hand to handle emergencies. The anonymous survey was distributed to 215 health care workers at five prisons in central Massachusetts.

Corrections Digest reported that complaints about Minnesota's $9.4 million-a-year contract with CMS soared from 118 in 1998, the year CMS took over the state's prison health care system, to nearly 200 in 1999. The Minnesota Nurses Association, which represents nurses who work within the Minnesota prison system, has complained that there are pharmaceutical errors and delays in obtaining medications. "I get calls where [nurses] are just frantic," association official Mary Kay Haas told the AP.

"I still haven't received any medical attention whatsoever," New Jersey prisoner Hatari Wahaki said in a letter he wrote three days before he died. The health care provider that ignored him to death was none other than CMS. "I consider what they are doing as literally playing with my life," Wahaki wrote.

The increasing privatization of prisoner health care is, indeed, playing with the lives of prisoners. And in an increasing number of instances it is resulting in prisoners dying--literally dying for profits. "We save money because we skip the ambulance and bring them right to the morgue," quipped nurse Diane Jackson to the St. Louis Post-Dispatch. Jackson was one of those disciplined in the death of Diane Nelson, 46, a mother of three and a prisoner at the Pinellas County Jail in Florida. Though Prison Health Services, Inc. (CMS's primary corporate competitor) provided health care services at Pinellas, Jackson summed up an attitude that is a deadly reality now at play in some of the nation's prisons and jails.

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