On the Inside: The Chaos of Arizona Prison Health Care
by Jimmy Jenkins, KJZZ.org
The Arizona Department of Corrections contracts with privately owned correctional health care company Corizon Health to oversee all medical, mental and dental care at 10 state prisons. However, that care has come under scrutiny in federal court.
In 2015, prisoners settled a lawsuit with Arizona over poor health care conditions in state prisons. More than two years later, Arizona and its provider have failed to meet the more than 100 stipulations agreed to in the settlement and a federal judge is threatening to fine the state millions of dollars. [See note at the end of this article; the district court imposed $1.4 million in fines in June 2018 as part of a contempt ruling]. Prisoners have testified in the settlement process to long wait times for medicine, delayed chronic disease care and a lack of access to specialists. The voices in this series confirm those allegations and more, recounting their experiences with the Arizona prison health care system.
Lucinda Jordan hadn’t talked to her father, Walter Jordan, for several years. He was serving time in an Arizona prison and they had lost touch. Then, one day in August 2017, the phone rang.
“He has a really strong voice and usually he’s pretty calm about things but I could tell he was really upset,” Lucinda Jordan said. Her father had called to tell her he had cancer.
“I asked him how bad and he said it was really bad,” Jordan said. “I asked him what kind of cancer and he told me it was skin cancer.”
Days later, Walter Jordan would file a notice of impending death with the Arizona Department of Corrections (ADC). He alleged that his cancer treatment had been delayed and was causing memory loss and pain. He predicted he might not make it another month. And then just weeks later, on Sep. 7, 2017, Walter Jordan died.
Now attorneys for the plaintiff class in the Parsons v. Ryan prison health care settlement are alleging a review of Walter Jordan’s medical records shows a history of delayed and inadequate care.
Dr. Todd Wilcox called Walter Jordan’s case “unfortunate and horrific” after reviewing his medical history at the request of plaintiff attorneys in the case. In his declaration, submitted in federal court, Wilcox says he believes Walter Jordan “suffered excruciating needless pain from cancer that was not appropriately managed in the months prior to his death.”
In his review, Wilcox states a dermatologist used improper medical techniques to treat Walter Jordan’s squamous cell carcinomas, including a four-square-inch section of Jordan’s scalp that was “electrically fried” with a process called electrodesiccation.
Wilcox writes the procedure made Walter Jordan “much worse, and burning a hole in his skull could cause the surrounding bone to die and become at risk of infection.”
Dr. Anna Likhacheva is a staff radiation oncologist at the Banner MD Anderson Cancer Center. She says with any kind of cancer, an early diagnosis means the patient will have a better chance at survival.
Doctors at the Banner MD Anderson Cancer Center use radiation therapy to treat invasive skin cancer.
“Some cancers that are easily curable at an early stage, if left untreated for years, can take someone’s life,” she said. Likhacheva says invasive squamous cell carcinomas “cannot be treated with just simple, do it at home procedures or in-office procedures. Those need either surgery or they need radiation therapy.”
Medical records show after months of seeing a dermatologist, Walter Jordan was finally referred to an oncologist. The referral came after a Corizon Health provider noted his rapidly deteriorating state. After evaluating a large wound on Jordan’s scalp, the provider wrote in all capital letters:
“THE WOUND IS HORRIFIC. PT IS EXPOSED TO THE ENVIRONMENT (DUST, DIRT, HEAT, FLIES) DIRTY HOUSING AND SHOWER FACILITIES.... I CANNOT STRESS HOW IMPORTANT IT IS THAT WE TAKE SOME SORT OF IMMEDIATE ACTION.”
Wilcox’s report says the medical records show by the time Walter Jordan received radiation therapy, the cancer had already penetrated his skull.
“It is difficult to fathom,” Wilcox writes, “how a squamous cell carcinoma could grow so large and so deep that it breached the skull and reached the brain, if the treating provider and the specialist dermatologist is vigilant and practicing within the standard of care.”
Corene Kendrick, an attorney with the Prison Law Office, had Wilcox review Walter Jordan’s records.
“Mr. Jordan’s care and what happened to him is sadly very emblematic of the deficiencies that we see in the medical care that’s being delivered by ADC and Corizon,” she said, “from the inadequate specialty care to the lack of pain management for somebody with terminal cancer, and also the failure to take basic preventative measures.”
Walter Jordan’s records show he was prescribed SPF 50 sunscreen by a provider. But a nurse reversed the order for sunscreen and suggested Walter Jordan buy his own, lower SPF sunscreen at the prison commissary.
In his review, Wilcox notes that Walter Jordan experienced “extreme pain throughout the last few months of his life. The medical record also documents Corizon provided him only Tylenol with codeine dosed twice per day.”
Wilcox writes this was not an appropriate treatment plan for a patient with cancer pain. “This pain management style with intermittent pain relief from a short-half-life medication is just wrong. It is actually the opposite of how cancer pain should be managed,” he said. “Appropriate management of chronic severe cancer pain should be accomplished using long-half-life opiates of adequate strength to ameliorate the pain.”
In his report, Wilcox says there are “many options for adequate pain management,” adding “there is no excuse for therapeutic nihilism (undertreatment) of cancer pain that appears to be the norm in the Arizona prison health care system.”
Kendrick says her office has been flooded with letters from Arizona prisoners making similar claims of inadequate treatment for pain by ADC and Corizon Health. “It appears that often times they are discontinuing the medication without the proper step-down or tapering schedule,” Kendrick said. “Some people are reporting to us that one day they are getting it and the next day they’re off.”
Arizona is not the only state where Corizon’s health care practices have come under scrutiny. The company has been sued hundreds of times in multiple jurisdictions across the country.
Randall Berg is the executive director of the Florida Justice Institute. His organization has sued Corizon multiple times over claims of malpractice while the company had a contract to treat prisoners in Florida state prisons.
Berg says Corizon was “not providing medical care known to be necessary and just generally exalting the profit motive over the provision of medical care.”
He says Corizon was reluctant to refer Florida prisoners to outside specialists.
“Any time they need to send somebody outside the prison walls, they have to pay for it,” Berg said of Corizon’s obligations under its contract with the state of Florida. He believes the company has a pattern of denying these referrals to save money.
Berg says he has frequently encountered Corizon’s refusal to provide adequate pain medication.
“We have a client who is in severe need of pain medication and we had to consistently sue the department of corrections and Corizon to obtain pain medication for him,” Berg said.
Stephen Swartz was recently released from custody after serving 10 years in the Arizona State Prison Complex-Lewis in Buckeye. He believes delayed care for prisoners with chronic illness is a serious concern in Arizona prisons. He says failures in the state prison health care system prompted him to become a named plaintiff in the Parsons v. Ryan case.
“I experienced, personally, the lack of medical care – the inadequate medical care – the wrong medical care – so I wanted to bring about change,” he said.
Swartz says he watched his cellmates and countless friends suffer and die from delayed medical care over the years.
“If we inflict pain and suffering upon these people – what’s going to happen when they come back out into society? They’re going to be damaged. They’re going to be hurt. And they’re going to – more than likely – reoffend.”
Swartz says he joined the class-action lawsuit because he still believes in the justice system.
Lucinda Jordan wears her father’s wedding ring. She says while he had committed wrongs in his life, she is proud of her father for speaking against allegedly improper medical care.
“I want to believe that it’s going to bring about change – that the federal government and the state government [are] going to step in and remedy the things that are wrong in the Arizona Department of Corrections.”
Lucinda Jordan says she hopes her father’s bold letter predicting his horrific death will spur the courts and the Arizona Department of Corrections to hold Corizon Health accountable for the well-being of the prisoners still behind bars.
“Because yeah he did some bad things – he did. But in the end he was trying to save some people’s lives. So I feel like it’s kinda his way to make up for what he done. And that’s a proud moment. And believe me I haven’t had too many of those.”
Dr. Jan Watson has seen a lot in her career. She’s worked on trauma teams in emergency rooms, practiced internal and occupational medicine. For most of her career she was an OB-GYN.
“Yes, I used to deliver babies,” Watson said, beaming with the joy of recalling the families she got to work with.
Birth, death and everything in between – after more than 30 years in health care, Watson thought she had seen it all. But then she took a job at an Arizona state prison.
“I had never seen anything like that in my life,” she said, her eyes taking on a distant gaze as she recalled her experiences. “I had inmates dropping left and right. It was kind of overwhelming and scary at first, but then, I just – became accustomed to it.”
For the past five years, Watson has been practicing medicine part time. She signed up with a company called ONYX MD, which is basically a temp agency for doctors. In May 2017, she got a new part-time offer.
“They told me it was with Corizon, and that company provides the health care for the prisons in Arizona,” Watson said. “And I said, ‘Oh, that sounds interesting. I’ll try it.’”
She agreed to a three-month contract with Corizon Health at the Arizona State Prison Complex-Eyman in Florence. She was a little nervous, but was told she’d be given a week of training from the Arizona Department of Corrections to prepare.
“I got to attend two days of my training, and then I got pulled to actually start seeing patients,” because she was the only doctor for more than 5,000 prisoners.
Watson says the pace was overwhelming.
“They would schedule 20 patients for you daily for multiple medical problems.”
She says she frequently treated prisoners with diabetes, high blood pressure, heart disease.
Watson says there were also frequent emergencies – called an ICS, which stands for Incident Command System.
“I call them inmate down situations, that was easier,” Watson said. She says prisoners would frequently come into her clinic unconscious.
“I have no idea what’s going on. Then my nursing staff don’t know what they’re doing, and I’m trying to tell them what to do and assess the patient.”
She tried to hold things together the best she could – with ace bandages and splints and a sense of humor: “But it’s just total chaos,” Watson said.
She says she thinks the problem comes from not having enough doctors. She would get emails from Corizon Health begging the providers to work overtime to deal with what they called “Operation Backlog.”
Corizon denies it was understaffed but “acknowledges backlogs occur from time to time due to provider absences, whether resulting from illness, injury, bereavement, or vacation. Seeking additional help from existing Corizon employees to eliminate such backlogs is both prudent and reasonable.”
However, emails provided by Watson show that the shortage of providers was significant. In his request for overtime workers, a Corizon employee notes that in October 2017 there were more than 800 outstanding requests for medical treatment.
Watson says getting medicine for prisoners was a constant challenge. “There were several inmates who had cancer and so they were taking morphine,” Watson said. Prescriptions were supposed to be filled by PharmaCorr, a correctional pharmacy provider owned by Corizon Health, but Watson says medications would often run out.
“So then I would have to write prescriptions and someone would have to go to Walgreens and get the morphine to tide them over until PharmaCorr could send us some more,” Watson said.
Corizon says from June 2017 through October 2017, “backup morphine prescriptions were only filled at Walgreens a total of nine times, which is a fairly limited amount for a five-month period.” Corizon did not respond to additional questions about the morphine prescriptions. The company said they believe Watson was not current in her prescription renewals. Corizon says this “contributed to the very problem about which she complained.”
As a provider at the clinic, Watson could refer prisoners to a specialist. When she first started at the prison, she says most of her referrals were going through. But then she says in August 2017, after she accepted an extension to her contract, things changed.
“It was just, ‘No, no, no,’ all the time,” Watson said of the denials she would get from Corizon.
Watson says referrals go through an authorization process within Corizon.
“There’s this utilization management team – these doctors somewhere that you never see who have to approve a referral.”
She said they started to vigorously challenge and deny her referrals. Even ones she thought were simple, like a prisoner with a broken bone.
“I got an X-ray, he hit his hand, and he had fractured his hand. That should have been a no-brainer,” Watson said. But she says the doctor who reviewed the case wrote back, asking her to find out how much rotation was in the displaced bone.
“I’m thinking, ‘What difference does it make? The man’s hand is fractured. He should go to ortho.’”
She says the referral was denied, so she pushed back.
“We went round and around about the angulation on this bone. We’re now weeks out after the fracture – I had never heard of such.”
She says another denial of care involved a prisoner who came in with a black eye because he had fallen and hit his head.
“This man would have episodes where he would have over 10 seizures in a row, and we couldn’t control him with all of the anticonvulsants. He was on like three or four.”
Watson says she asked for an EEG – a brain scan – and it was denied.
“So we have this man who goes around and periodically has these episodes of multiple seizures and we couldn’t get him to a neurologist.”
Finally Watson says she reached out to her medical director and asked why the prisoner couldn’t be sent to the hospital.
“It cost too much money,” Watson says was the response. So she asked what the plan was to keep the prisoner from hurting himself.
“‘Oh, well, we’ll order a helmet for him to protect his head,’” Watson says was the suggestion for treatment from the medical director.
But Watson says she kept pushing back on the denials.
“I would go search medical journals to find data to support my side,” she said. “But I’m just thinking, ‘Why do I have to go through this to get care that is so obvious.’”
Watson says she was asked to cancel referrals to an infectious disease specialist for HIV patients because, according to Corizon, they did not have a contracted infectious disease specialist.
Corizon confirmed 18 appointments were canceled from July 1, 2017 through the end of September 2017.
“Eighteen appointments were canceled, and of those, 12 of them were canceled by the specialty physicians’ offices themselves and not by Corizon or its providers,” Corizon said. Corizon did not respond to follow-up questions as to why the specialty providers allegedly canceled the appointments.
Even if a referral was approved, Watson says that was still no guarantee the patient would receive care. She says Corizon would ask her to cancel referrals that were approved but had yet to be completed so the company could avoid fines.
Watson says the Utilization Management team at Corizon would suggest what were called alternate treatment plans, which she says often suggested the provider on site handle the request.
“I am the provider on site,” Watson said. “I’m the one who wrote for this!”
The Arizona Department of Corrections and Corizon Health are being monitored by a federal judge as a part of the Parsons v. Ryan settlement agreement. But Corizon keeps its own numbers. Watson says a woman responsible for the monitoring was open with her disregard for the process.
“When we had this provider meeting – she even said at the meeting, ‘Well, let me tell you how to beat the monitor,’” Watson said.
Corizon says “if the term ‘beat the monitor’ was ever used, it would have been in reference to how Corizon can properly improve its scores and did not (and does not) reflect any effort to mislead monitors or the Court.”
She was losing confidence in the system. Watson said there was one case, however, that impacted her the most.
“A gentleman came in with chest pain,” Watson said of a prisoner. “He was known to have heart disease.”
His symptoms, combined with an EKG, made Watson think he was having a heart attack, but she couldn’t get approval for him to go to the hospital for hours.
After the referral was finally approved, Watson’s fears were confirmed. The prisoner had suffered a heart attack.
Watson says her medical director, Dr. Rodney Stewart, reviewed the prisoner’s test results from the hospital and conveyed the treatment plan to her and the prisoner.
“He told me that’s what had happened with the patient. He had had a heart attack. None of his arteries could be bypassed and so there was nothing that could be done,” Watson said of her conversation with Stewart.
“I was told if he ever came in with chest pain again to just let him die, keep him comfortable, because there was nothing we could do about it,” Watson said.
She says she couldn’t believe what she had heard. Corizon says Dr. Stewart “denies having made such a statement.” Watson stands by her memory of the statement, which she said was made in the presence of others, because it was so alarming.
“You know, this wasn’t like a do not resuscitate,” Watson said. “This was, if the man had chest pain – I’m not supposed to treat that? I’m just supposed to let it continue and let him die?”
Watson says she pulled the prisoner’s medical record and looked at the notes from the hospital. She says what she saw conflicted with what the Corizon medical director told her.
“It didn’t say none of the arteries could be bypassed,” Watson said. “It only said one couldn’t. One could. And another could benefit either from medical management and/or a stent.”
Watson created a new plan. She prescribed the prisoner nitroglycerine to take the next time he had chest pains. And she told him she wouldn’t let him die.
Shortly after she changed the prisoner’s plan, Watson says she was called in to a meeting with Stewart and the area medical director.
“I was told I was not doing things ‘The Corizon way,’” Watson said. She says when asked what the “Corizon Way” was, she was given a list of don’ts.
“Don’t make so many referrals. Don’t order so many splints. And I had to be faster. Don’t talk so much to the inmates,” Watson said.
Corizon says there is no company policy entitled the Corizon Way, but confirms Dr. Stewart said it. “When Dr. Stewart used this term,” Corizon said, “he was referring to applicable patient care standards. He merely used this phrase as a term of art.”
At this point, Watson told her medical director she was going to have to have a talk.
“And he says – ‘Well, you and I?’ And I said, ‘No. I’m going to have to have a talk with myself, because every day you come up with something that prevents me from providing care.”
Watson put in her 30-day notice and left Eyman in early October 2017. During her five months at the prison, she sent multiple emails requesting more resources and asking why her patients were being denied care. She says she never filed a complaint within the company because she didn’t think it would do any good. She believes Corizon Health was too focused on its bottom line.
“Corporate-run medicine is really big on numbers, but numbers do not tell you anything about the quality of care,” Watson said. “And if they actually went about it the other way and actually focused on, let’s deliver good health care, the numbers would fall into place.”
Watson says she would return to prison health care under different management. She says she misses the prisoners. She liked them. After a while, Watson said she didn’t even think of them as prisoners anymore.
“A patient is a patient,” Watson said. “Doesn’t matter where they are or who they are, I have to treat them the same.”
Ed. Note: Prison Legal News has repeatedly covered poor health care in Arizona prisons. [See: PLN, May 2018, p.28; April 2017, p.48; Feb. 2016, p.56; July 2013, p.1; Sept. 2012, p.34]. The class-action settlement over inadequate medical treatment in Arizona’s prison system remains ongoing. In June 2018, the ADC was held in contempt by the federal district court overseeing the settlement, which found “wide-spread and systemic failures.” The court imposed $1.4 million in fines. Corizon reimbursed the state for the fines, and state prison officials have appealed the contempt finding to the Ninth Circuit Court of Appeals. On October 2, 2018, KTAR.com reported that the attorneys representing prisoners in the case are now seeking $1.6 million in fees and costs, in addition to the $6.1 million they have been awarded since the class-action lawsuit settled. See: Parsons v. Ryan, U.S.D.C. (D. Ariz.), Case No. 2:12-cv-00601-DKD.
This investigative article was originally published by KJZZ.org on December 18, 2017, with art and graphics; it is reprinted with permission, with minor edits. Copyright KJZZ.
Related legal case
Parsons v. Ryan
|Cite||U.S.D.C. (D. Ariz.), Case No. 2:12-cv-00601-DKD|