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Federal Court Orders Independent Evaluation, Training And Credentialling Of All California Prison Healthcare Practitioners

Under pressure from U.S. District Judge Thelton E. Henderson, who earlier in 2004 threatened wholesale federal court takeover of the California Department of Corrections (CDC), the CDC stipulated to an order aimed at ending the use of untrained, unqualified and/or incompetent doctors, nurses and physician assistants in its $1 billion per year prison health care program. The centerpiece of the September 17, 2004 Order is its requirement for CDC to hire an independent entity" for these purposes within 60 days, thus wresting control of past questionable medical staffing practices from prison bureaucracy. The Order issued under the court's continuing oversight of prison medical care under Plata v. Schwarzenegger, wherein the prisoners are represented by attorneys Steve Fama and Alison Hardy of the San Quentin, California based Prison Law Office.

Designed to weed out incompetent physicians, the expected shake-up could result in 261 prison doctors being stripped of their ability to practice medicine in CDC's prisons until they complete a stringent medical training course. This is a concrete step toward getting rid of those who have been harming patients," Hardy said.

While admittedly, the news of proper health care is rarely reported, the stories of improprieties reverberate because they are so disturbing. At one CDC prison, four of the eight physicians had criminal records, mental health problems or loss of privileges at local hospitals. When CDC tried to fire one of them, the State Personnel Board reversed the action.

In another prison, seven of twenty credentialed physicians had problems, including mental health issues, alcoholism, and loss of privileges or licenses because of substance abuse, incompetence, or both. In yet another prison, HIV care was managed by an obstetrician, and a neurosurgeon handled emergency room care for internal medicine problems even though he was not trained in emergency medicine.

Perhaps more disturbing was that the internal oversight of prison physician credentialing was itself suspect in one prison where the vice-chairman of the credentialing committee was an obstetrician who had lost his license for 7 years because of incompetence and alcoholism. Plainly, the court's stripping of such internal abuse from CDC was central to its Order to transfer all medical staffing authority to an independent entity.

The six-page stipulated Order addresses (1) evaluation of physicians, (2) treatment of high-risk patients, (3) classification and supervision of physicians and nursing, and (4) medical scheduling and tracking.

Of utmost importance is the 60-day time-fuse to engage the independent entity to credential CDC doctors - the number one priority. The Order calls for a roll-out beginning immediately, and to be completed by December 31, 2005. Physicians with clinical responsibilities shall be fully processed by June 30, 2005. The independent entity shall classify each doctor as Category 1 (competent to provide care without remedial training); Category 2 (competent to provide care upon completion of remedial training received from the independent entity); or Category 3 (not competent to provide care to class members, or failed remedial training). A special certification will be required for doctors assigned to treat high-risk patients. An important caveat is that CDC is forbidden from hiring independent contractor primary care physicians who are not board-eligible in internal medicine or family practice. Monthly progress reports to the court shall begin January 15, 2005. By November 1, 2005, a plan to assess and train nurse practitioners and physician assistants shall be submitted.

A plan shall be submitted to identify all high-risk patients. By November 1, 2004, independent physicians approved by court experts shall evaluate and treat all high-risk patients at California State Prison-Sacramento, California State Prison-Corcoran, Central California Women's Facility, and Salinas Valley State Prison. If the court experts deem such care is needed at other prisons, they shall so determine and provide.

By November 1,2005, CDC shall submit a plan to reclassify all physician categories plan for hiring regional medical directors is due December 1, 2004, whose duty includes revising the medical staff hiring process - to be effective January 15,2005. By March 1, 2005, further plans are due regarding on-site clinics through a residency affiliation program, to aid prisoners with complex medical problems.

Finally, also due by March 1, 2005, is the funding and implementation of at least one position at each of the roll-out institutions to support execution of the medical schedule and tracking system. And to keep things honest, not less than nine Quality Management Assistant Teams (QMAT) shall be operating by March 1, 2005 to monitor compliance with the Order.

This Order was sorely needed. Overall, records show that 20% of all CDC physicians had seriously blemished pasts - a rate five times the figure statewide. In a recent legislative committee hearing, State Senator Jackie Speier commented, To put it very bluntly and very simply, the healthcare system at the California Department of Corrections is sick." Senator Gloria Romero added, The sad fact is California has been growing its inmate population but has failed to provide adequate healthcare for those locked away." The Senators referred explicitly to the recent tragedy of Solano State Prison prisoner Anthony Shumake dying of complications from an extracted abscessed tooth. [See: PLN, April, 2005.]

Recently appointed CDC Director Jeanne Woodford testified her concern. We know we have many challenges in our efforts to provide quality healthcare. We want to fix what this committee has called a broken system... and become known as a state that uses the best practices in all aspects of its healthcare system." The Senators appeared impatient, wanting to know why the federal prisons have been able to reduce their prison healthcare costs while California's had soared. The scratching of heads is no longer acceptable," Speier said, absent any good answer to her question.

But a fair statement of the challenge is that prisoners bring with them a sicker profile than the average population. One in five has serious mental illness (a probable carryover from the decision by former Governor Ronald Reagan to close most state mental hospitals -relegating those persons' fate to CDC); one-third are infected with hepatitis C [recent estimates put this at 40%]; and HIV/AIDS in prison is five times the national average.

Nonetheless, there is no excuse for roadblocks such as that reported by Dr. Scott Anderson of CDC's California Medical Facility, who testified that physicians there sometimes lack essentials as basic as an examining table, soap and towels with which to dry their hands. He also pointed to a severe shortage of nurses and medical technical assistants, as well as the absence of computers to track medical records, view X-rays and help with medical decisions.

The new competency testing for doctors may have the paradoxical effect of driving good doctors out of the system, Anderson testified. He considers his board certification in specialties such as rheumatology and geriatrics a sufficient validation of his skills. Ironically, these skills make him uniquely desirable today for California's prisons, where the greatest driver to medical cost growth is the aging of tens of thousands of parole-eligible life" prisoners for whom the state abjectly refuses its duty to set a parole date. See: Plata v. Schwarzenegger, U.S.D.C. (N.D. Cal.), No. C-01-1351 T.E.H., Stipulated Order re Quality of Patient Care and Staffing, Sept. 17, 2004.

Other sources: Los Angeles Times; Contra Costa Times.

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Related legal case

Plata v. Schwarzenegger