“Do no harm” or “Do no expense”?: Ohio’s prisoners are dying from inadequate medical care

Ohio Department of Corrections' health care budget cuts and poor oversight is compromising the quality of care.

by Peter Wagner, November 24, 2003

Ohio’s prisoners are dying from inadequate medical care

In August, the Columbus Dispatch and WBNS-TV published a multi-part exposé of the inadequate medical care in Ohio’s prisons. The series exposed wrongful deaths, inadequate care and questionable doctors. Almost 2,600 Ohio prisoners are known to be infected with Hepatitis C and health officials estimate the true figure to be closer to 9,000. As of July, the number of prisoners receiving treatment for Hepatitis C was 16. In September, the Prison Reform Advocacy Center in Cincinnati filed a class action lawsuit challenging these conditions.

The attention from the series brought shock from the Department of Corrections and Rehabilitations, but the problems appear to be the result of neglect engineered at the budgetary level.

This year Ohio will spend $122.6 million on prison health care. That’s not counting the $1.15 million in judgments and settlements over the last 3 years. This year, 25 of the prisons had their health care budgets cut an average of 11%. While medical care costs have risen 19% nationally since 2000, Ohio’s spending on prison health care has risen just 9%.

In 2002, the DRC’s health care director Kay Northrup asked medical providers to change their message to prisoners when denying care. Instead of explaining that a treatment refusal was based on budgetary reasons, doctors were to give out only clinical explanations. A year earlier, she ordered prison podiatrists to stop ordering special footwear for prisoners with unable to walk in the stiff-prison issued “shoes”. Admitting that the cheap shoes caused many foot problems, she restricted the doctors to ordering replacements only for diabetics who developed foot ulcers. The remainder of the injured were left, in the words of the Columbus Dispatch “hobbled”.

Restricting care, $3 at a time.

Ohio charges a $3 co-payment on medical visits to discourage them. The DRC director implies the fee cuts down on frivolous visits without impacting good health care, but administrators at Pickaway and Belmont Correctional Institutions disagreed when they suspended the fees after an outbreak of staph infections.

The co-payment has raised $1.7million since 1998 intended to fund expensive equipment purchases, but $1million of the money remains unspent.

Three dollars for a medical visit may not seem like a lot of money to people on the outside, but Ohio prisoners make only $18-24 a month. The Columbus Dispatch estimated that the $3 copayment would be the “equivalent of $594 to the average Ohio household earning $47,521 a year.”

Low-quality doctors

One of the doctors highlighted in the Columbus Dispatch was Dr. Adil Yamour, whom the London Correctional Institution’s health care administrator requested be replaced because he “orders ibuprofen for everything, regardless of the diagnosis.” The situation gets more frightening when you factor in his defense: he was asked to see 70 to 93 prisoners in an eight hour shift. Yamour was also criticized for telling prisoners he could not order certain procedures or medications because of lack of funding, which he claims was true. In any event, this doctor who the Department of Corrections and Rehabilitation thought should be replaced was let go, and then started treating patients at Pickaway Correctional Institution via contractor Clinicare.

This may not be an extreme case. Dr. Shura Hedge was fired in 2001 after he was caught spending only 10 minutes to give full mental health evaluations, and he was giving the same assessment scores to 30 of 31 prisoners, “some of whom where psychotic.” He was hired by the privately-operated state prison across the street. The Columbus Dispatch identified two other medical workers who were fired or non-renewed and then resurfaced at other prisons. Although the state has veto rights over the personnel decisions of its private prison operators, Hedge is still working at his new prison.

Bad apples in rotten prison barrel

These bad apples are a structural product of Ohio’s policy of relying on outside contractors on lump-sum contracts. While the contractors do comply with requests to remove problematic doctors, no company has ever lost a contract for poor performance. The results are as unfortunate as they are unsurprising because the prisoner-patients are powerless and the DRC fails to require quality.

Likewise, the state has failed to do background checks in a timely way for its doctors. Dr. Ayman Kader worked in two Ohio prisons for more than a year while under a 35-count felony indictment for drug trafficking and writing bogus prescriptions for amphetamines.

Complicity for the poor care runs to the top. “We do have to tolerate a different standard sometimes because it’s hard to get people to come and work in the prisons to provide medical care,” says the DRC’s spokeswoman Andrea Dean. (See sidebar, International law and prisoner health for more on this claim.)

The contractor who hired Kader and called him “one of our most valued, cooperative physicians” echoed a similar sentiment to Dean: “People do not go to medical school dreaming of some day working in a maximum security prison.” The medical providers can be glib that “you get what you pay for” because they make a profit by providing doctors — inferior or otherwise — to the prison. The Department’s tolerance of the problems is harder to understand, unless adequate care is of no concern.

Working in a prison is not a prestigious job, but the pay scale reinforces rather than addresses the problem. While the comparative pay received by Ohio’s contractors was not available, other data collected by Human Rights Watch suggests that poor performance of prison doctors is by design, not accident. In Maine, a psychiatrist would make $20,000 less working in a prison than in the community. Virginia pays its prison psychiatrists $3,251 less per year than it pays school psychiatrists.

Ohio reduced prison medical costs by first replacing its own doctors with contractors paid on a per-hour basis and then with a series of fixed-rate contracts. Each year’s winning bid becomes the maximum amount the Department will pay in the next year. Under the hourly contractor system, Ohio paid $312,000 in wages at the typical prison in 2001. The current figure is $175,000, or 56% less.

Locked in to medical neglect

Unlike other victims of poor medical care, prisoners don’t have the ability to get a second opinion. Instead, prisoners are required to file administrative grievances. Attorney Alphonse Gerhardstein summarized the procedure: “The medical grievance goes to a bureaucrat, the bureaucrat then sends it to the medical staff, who then say, ‘We’re giving fine care. What’s the inmate griping about?’ Then they send the grievance back and deny it.”

The state’s own consultant recognizes the medical grievance system is broken, suggesting in 2001 that the grievances get independent medical review. No action was taken. And perhaps the State likes the lack of oversight. The legislature’s Correctional Institution Inspection Committee, which is supposed to oversee the prison systems, has gone without funding for staff for two years and this year is getting funding at only half of its previous amount.

Following up

What needs to be done is obvious. As Dr. Ronald Shansky, the former medical director of Illinois prisons told the Columbus Dispatch, that Ohio “‘needs an independent, outside team of correctional medical experts’ to review prison medicine…. ‘If the concerns are serious, the state should want to know. Is it getting a bang for its buck or is it creating liability?'”

The Department has created a commission to study the issue and recommend changes. The report, due at the end of the year should provide a clue as to whether Ohio policymakers want to provide adequate health care for its incarcerated citizens or adequate salaries for Department lawyers to defend lawsuits.

The Commission has hired the former head of the New Mexico DOC to assist, but the commission is all Department employees including Kay Northrup, the Deputy Director of the Office of Correctional Health Care and author of the memo instructing doctors to not tell prisoners the truth: that financial restrictions are determining their treatment.

Worse, perhaps, is the message sent to the Commission by the Department’s Director, Reginald Wilkinson. He acknowledges that reforms may cost money, but he’s “not throwing in the towel on money at this point” in the hopes that the Commission finds new ways to further cut the medical budget.

Sources: Columbus Dispatch, Human Rights Watch, Ill Equipped: U.S. Prisons and Mental Illness. The Andrea Dean quote can be seen online in the August 25, 2003 Cincinnati Enquirer Report: Waits lengthy to see prison doc.