Kentucky jails' for-profit health care problem

For two days, Ronald Gaunce lay in the Montgomery County jail, wracked with pain from severe drug withdrawal and awaiting medical care that never came.

Meanwhile, Ronald Waldridge, Gaunce’s taxpayer-funded doctor, was 80 miles away in Shelbyville. Waldridge neither spoke to nor examined Gaunce before he died of a seizure on March 25, 2013.

Waldridge was a busy man. Four days a week, he saw as many as 24 patients a day -- more than the national average -- at his private office. But he also had a side job: “medical director” at 21 Kentucky jails for Southern Health Partners, a private, for-profit health care company.

Ten of those jails were at least 90 miles from Shelbyville. All told, Waldridge was responsible for the medical care of about 3,500 inmates -- nearly a fifth of the state’s entire jail population.

Waldridge’s contract with SHP called for him to spend one to three hours each week at the Montgomery County jail. But he actually went there only every two or three months, and then just for brief periods, according to court testimony.

Waldridge and Southern Health Partners represent a jail health care model entrenched in Kentucky and beyond. But it runs counter to national standards, and often falls far short of meeting inmates’ critical medical needs, WFPL’s Kentucky Center for Investigative Reporting found.

Jails buy medical care they can afford. Companies like Southern Health Partners make a profit. But promised and required services are not always provided. Inmates suffer as a result. And virtually no one is doing anything about it.

“‘Doing the time’ is supposed to mean living in a jail with your liberty taken away, eating jail food, with unsavory characters. It doesn’t mean dying because your basic medical needs are just flatly ignored,” said Greg Belzley, a Louisville attorney who has sued companies, jails and doctors repeatedly over substandard medical care for inmates.

Waldridge hired advanced-practice registered nurses, or APRNs, who made weekly visits for him at the Montgomery County jail and the 20 others for which he’d accepted responsibility. Lower-level nurses, LPNs employed by SHP, were charged with providing daily jail medical care.

The use of these nurses, which conforms with state regulations, also suited SHP just fine.

Based in Chattanooga, Tennessee, SHP contracts with about 30 jails in Kentucky and more than 200 in 13 states. Another for-profit company, Advanced Correctional Healthcare, in Peoria, Illinois, serves approximately 250 jails in 17 states, including more than 20 in Kentucky.

In all, nearly two-thirds of the state’s jails do business with Southern Health Partners or Advanced Correctional Healthcare.

The companies also are active in state politics, courting local officials, supporting their organizations and donating to campaigns.

The sometimes-fatal shortcomings of jail health care seldom attract public notice -- or much keen interest from the Kentucky Department of Corrections. The state agency rarely does in-depth investigations of jail deaths, let alone non-fatal grievances.

Meanwhile, the DOC has done its part to further the for-profit jail health care model. In 2011, the department requested that a state regulation be amended to specifically allow LPNs as well as doctors and higher-level nurses to serve as a jail’s “medical authority.”

KyCIR repeatedly requested an explanation from the DOC for the change, but the department never provided one. Indeed, it refused even to acknowledge that it sought the change, despite the fact that documents obtained by KyCIR show the department filed the proposed change with the state Legislative Research Commission on May 6, 2011.  The change was approved five months later.

Despite the department’s hands-off attitude toward jail health care, lawsuits filed by inmates or their survivors paint a stark picture of negligence or indifference by medical-care providers and, in some cases, jail personnel. And several recent federal court opinions in Kentucky have taken both industry and jails’ practices to task.

SHP appears unconcerned about its medical directors’ workloads.

In a lawsuit filed by Gaunce’s mother following his death, SHP President Jennifer Hairsine testified last October that she had no idea how many jails Waldridge or other contract physicians covered for SHP. Nor did she care.

“I guess as long as they can perform their duties, we're fine with the number that they have,” Hairsine said.

Waldridge acknowledged last May in the same lawsuit that his $1,200 per month contract with SHP in Montgomery County required a physician to be at the jail up to three hours weekly. But the fact that he went there just four times a year suited Southern Health Partners just fine, too.

“He and I had a conversation and … I have allowed him to send a physician provider in his absence,” Hairsine said.

Hairsine declined to be interviewed for this story. Instead, she sent an email defending SHP’s practices and business model.

Waldridge also declined to comment. “I don’t think it would serve me well to engage in that interview,” he said.

But Diana Rice, Gaunce’s mother, has plenty to say. Nearly three years after his death, Rice is still grieving -- and angry.

“This should never have happened,” she said.

Rice said she once naively assumed that people in jail “have a right to a certain degree of basic medical care, and that if something is wrong with you, you get that medical care. And that didn’t happen with Ronnie.”

Thirty-seven-year-old Ronald Gaunce was arrested on March 19, 2013, accused of selling pills prescribed to him for a back injury. At the Montgomery County jail, he told a deputy he was “in bad shape.”

Just an hour before he died, Gaunce was found covered in his own feces and had to be wheeled to the shower because he was too weak to walk. There, he suffered a seizure and stopped breathing. He died soon after at a local hospital.

Waldridge’s APRN for the jail never saw Gaunce. He was locked up after her brief weekly visit and dead before she returned, according to court records. The APRN also covered four other jails for Waldridge in central and eastern Kentucky, mostly in a single day. And she worked part time at a Frankfort clinic.

The only in-person medical attention Gaunce received at the jail came from its nurse, who was not qualified to diagnose or treat him. The nurse testified in the federal lawsuit, which is pending, that she spoke with Waldridge by telephone twice before Gaunce died. Waldridge, however, said under oath he had no recollection or notes of those conversations. 

Inmates’ medical costs are a significant expense for counties, often several hundred thousand dollars or more per year. One way local governments seek to control those costs is by striking deals with providers such as Southern Health Partners and Advanced Correctional Healthcare.

The companies do well, too. Hairsine has testified that SHP strives for a 10 percent profit margin.

SHP’s website describes the company as “your partner in affordable inmate health care.” Under the headline, “Why Choose Southern Health Partners?”, the webpage has a piggy bank inscribed with a dollar sign and the words “cost savings” underneath.

SHP cites efficiencies like purchasing in bulk as a means to offer quality care at reasonable prices. Much less discussed is its system of dispensing a significant portion of on-site jail medical care through less experienced, less trained, lower-salaried LPNs.

Meanwhile, the jails’ medical directors bank six-figure incomes while serving largely as figureheads, providing the appearance of credibility but little or no regular care for inmates and rendering minimal supervision of those who do.

Based on his his $1,200 per month stipend for the Montgomery County jail and what he paid the APRN to cover for him, Waldridge could have cleared $130,000 annually for the care and oversight he provided statewide on behalf of SHP. He acknowledged in his court testimony that most of his time on behalf of the company was spent “on call,” being available to answer questions or discuss problems by telephone.

“You get what you pay for,” said Ray Sabbatine, a former Fayette County jailer and now a corrections consultant, said of the decision to make LPNs the primary caregivers in jails. “It’s pretty simple, it’s a financial issue. LPNs are 20 to 30 percent cheaper than an RN or any higher-degreed medical provider.”

SHP’s website also proclaims that “all of our programs use” standards including those of the National Commission on Correctional Health Care “as a basis for” SHP’s policies and procedures.

But the NCCHC’s general guideline for jail medical care calls for a physician to be on site three-and-a-half hours per week for every 100 inmates there.

If SHP had followed that guideline in Montgomery County, Waldridge or another doctor would have gone to the jail for more than six hours each week -- perhaps nearly as much time as Waldridge spent there in a year.

APRNs -- registered nurses with a graduate degree -- have less education and training than doctors. But they perform many of the same tasks, including diagnosing and treating medical conditions and prescribing certain drugs.

Under the NCCHC guideline, an APRN can substitute for “a portion” of the physician’s time seeing inmates. But jails are supposed to provide “justification” for the hours covered by the APRN.

While companies are more likely to win a jail’s medical-care contract by promising lower costs, the for-profit model tends “to cut corners and inmates are less likely to get the health care they’re constitutionally entitled to,” said Michele Deitch, an authority on corrections who teaches at the University of Texas.

“County officials may think they’re getting off the hook by privatizing the services, but they can’t contract away their constitutional obligation to provide quality health care,” Deitch said. “The failure to do so is going to result in deaths and serious injuries and illnesses, as well as lawsuits.”

Locked up in Hopkins County on April 8, 2010, for misdemeanor assault, Tyler Butler vomited twice while changing into a jail uniform. He was sweating profusely and had trouble standing up. His skin was gray, and he told several jail deputies and Southern Health Partners employees that he had a staph infection, according to an opinion issued last month by the 6th Circuit U.S. Court of Appeals.

Deficiencies in his care at the jail are vividly described in the court’s opinion in the pending case.

Although the 25-year-old’s condition was critical, SHP’s nursing staff did virtually nothing to help him. Inmates generally had to request medical care before any was provided, “even if the circumstances called for emergency medical treatment.”

The Licensed Practical Nurses, or LPNs, were not familiar with the company policies for dealing with detoxification (where Butler had been placed for suspected drug use), or for potentially life-threatening staph infections such as Butler’s. And they had received little or no training in how to handle such dire cases, according to the court opinion.

LPNs are not qualified or permitted to diagnose or treat illnesses. But they can assess and document inmates’ medical conditions, dispense treatment ordered by a physician and monitor progress.

The nurses did none of that in Butler’s case. Nor did they consult with the jail’s contract physician about how to manage Butler’s care, even though SHP policy dictated that detoxification be conducted “with physician overview.”

On Butler’s fourth day in jail, a nurse found him without a pulse and cold to the touch. But she made no effort to revive him. Instead, she tried -- unsuccessfully -- to call the doctor. Then she summoned an ambulance. The county coroner arrived a few minutes later and pronounced Butler dead.

SHP President Hairsine came to the jail the following day, spent about two hours doing a cursory review and left. She proclaimed to the jailer that “‘everything looks fine,’ and demonstrated no concern that SHP personnel had acted improperly,” according to the court’s opinion.

Betty Dawes, SHP’s regional administrator, acknowledged that she neither offered any training program nor ensured that the nurses were taught how to carry out their responsibilities, according to the opinion. Indeed, it said, no SHP official, including Hairsine, took responsibility to train nurses at the jail or provide them with “appropriate supervisory oversight” to avoid violating inmates’ constitutional right to “adequate medical treatment for their serious medical needs.”

Although Dawes conceded that the jail’s nurses disregarded SHP’s policies and procedures in Butler’s case, no one was counseled or disciplined following his death. Nor was any remedial training given.

“Butler’s urgent need for medical treatment was apparent the moment he walked through [the jail’s] door, yet SHP staff did not provide it,” despite his requests and those of jail deputies, the court found.

And all of this occurred despite Kentucky corrections policy, which holds that Butler was entitled to health care comparable to the level of care “available to free citizens in the surrounding community.”

The Hopkins County jail’s contract with SHP stated that a physician would go there twice a week, and for 16 to 25 hours per month. But Dr. Henry T. Davis has acknowledged in the lawsuit, filed by Butler’s mother, that he only went to the jail for an hour or two every other week. Davis also served as SHP’s medical director for jails in Henderson and Daviess counties, which he visited weekly. In addition, he worked at an Evansville, Ind., hospital.

Davis further testified that he had no responsibility to train or supervise the jail’s nurses. But appropriate oversight is precisely what’s lacking in the for-profit companies’ business model, Belzley, the Louisville attorney, said.

“The problem isn’t the use of LPNs,” he said. “The problem is the complete lack of supervision by an APRN or an MD.”

In the Butler lawsuit, claims against two SHP nurses, the county and deputy jailers were settled last year for a total of $345,489. Claims against other SHP employees and the jailer were dismissed. The company is the only defendant remaining. 

Although neither SHP nor the state Department of Corrections has acted in response to jails’ and health care companies’ over-reliance on LPNs for inmate medical care, the federal government has taken notice.

During its decade-long investigation of the Grant County jail, the U.S. Department of Justice has repeatedly chided the jail for that, and for having a doctor on site only two or three hours weekly. These “medical staffing deficiencies pose an unreasonable risk of harm to inmates,” the department told Grant County government in a February 2013 letter.

Since then, however, little has changed, even though a jail inmate died just a month later as the result of allegedly inadequate health care.

The jail’s medical director at the time of that death testified earlier this year that he called on the jail just once a week, usually for three hours or less. Dr. Nadir Al-Shami said he worked full time for Advanced Correctional Healthcare while also maintaining a private practice in southern Jefferson County, 100 miles from Grant County.

In addition, Al-Shami served two other jails and a state halfway house in central Kentucky, and three more jails in central and Southern Indiana, according to his testimony in a federal suit over inmate Danny Burden's death.

Al-Shami, who refused to be interviewed by KyCIR, testified that he routinely went to all four Kentucky facilities on the same day, spending 30 minutes to three hours at each.

Under the NCCHC guideline, the three jails merited at least twice as much of Al-Shami’s time as he gave them.

Jessica Young, ACH’s senior counsel, did not respond to several requests for an interview, or to written questions submitted to her via email.

For-profit providers such as SHP and ACH are significant players in the Kentucky political arena. They join organizations of local officials, including jailers and county judge-executives. And they’re a visible presence at those officials’ conferences, setting up booths and sponsoring events such as dinners, golf scrambles and fishing competitions.

SHP also pays the Kentucky Association of Counties $50,000 a year to be identified by KACo as a “premier sponsor.” Rich Ornstein, a KACo attorney, said the organization agreed to the sponsorship in 2007 because “there was a need for better medical services within jail facilities.”

In exchange for SHP’s annual payment, Ornstein said KACo has identified SHP as a “premier partner” on its website as well as at KACo’s annual conference, and “has endorsed SHP’s inmate health care program.”

Asked whether KACo is aware of litigation challenging the quality of SHP’s jail health care, Ornstein said, “We have been generally pleased with SHP's performance, and they have always been very responsive to our inquiries.” Asked to elaborate, Ornstein replied, “We have nothing to add.”

Ornstein also said KACo, which lobbies the legislature and provides insurance to most of the state’s 120 counties, does not have sponsorship agreements with any other jail health care provider.

Some company officials also are political contributors. Jeffrey Reasons, the current board chairman of Southern Health Partners, has donated nearly $11,000 to Kentucky political candidates in the past decade, mostly to candidates for jailer and the state legislature.

Waldridge is one of several doctors with medical-director contracts with the companies and who also are campaign donors, mostly to legislative candidates.

Dr. John Adams was SHP’s medical director at the Hardin County jail in the spring of 2010, when inmate Mark Sietsema became seriously ill there. The jail is 92 miles from Adams’ office in Simpson County, and he went there for an hour or two each month, according to his testimony in a lawsuit filed by Sietsema.

Until he resigned in April 2011, Adams was the company’s medical director for at least nine jails housing more than 1,600 inmates. In addition, he maintained what he described as “a very busy” private practice in Simpson County, near the Tennessee border.

Adams’ contract with SHP called for him to provide approximately five hours of medical care per week at the Hardin County jail. Even that would have been less than half the NCCHC’s minimum benchmark for a jail that size.

SHP’s Hairsine has testified in the pending suit that Adams’ APRN could fulfill his weekly requirement at the jail. She was unable to say how often Adams or his APRN actually went to the jail.

Adams and SHP relied heavily on the jail’s nursing staff. But neither Adams nor his APRN was notified that Sietsema was in critical condition until after he was hospitalized and underwent emergency surgery that saved his life.

Sietsema, who had a history of diverticulitis, a potentially fatal intestinal disease if left untreated, contends that he received essentially no medical care for four days in custody prior to collapsing and being rushed to the hospital.

He has since recovered, but his critique of his care in the jail is harsh.

“No matter how much I begged, I couldn’t see” a nurse or a doctor, Sietsema said in an interview. “It was like I was fakin’ all this. The medical treatment was just horrible.”

SHP paid Adams $3,000 per month for his services at the Hardin County jail. In total, he said he received about $160,000 annually for all the jails he oversaw. He didn't say whether that figure included his nurse's salary.

Adams’ infrequent jail attendance also surfaced in connection with the 2009 death of Shannon Finn in the Warren County jail. Testifying in a lawsuit resulting from Finn’s death, Adams said he visited that jail every six to eight weeks for an hour or two, but that his APRN went there weekly for four to seven hours. Under the NCCHC guideline, a doctor or APRN should have spent 13 or more hours there per week.

Court records show SHP and its nurses settled the case in 2013 for a confidential sum. A jury ruled in favor of Adams, the county and the deputy jailers. The case is still pending against the jailer.

Adams, who refused to be interviewed by KyCIR, has testified that he told the company before he was hired that he would be using an APRN to perform regular jail visits for him.

“They said they had no problem with it at all,” Adams said in his testimony. “They said that was the standard in most of the jails across the United States now.”

But Diana Rice said that standard wasn’t good enough for her son in the Montgomery County jail, and doesn’t do justice to other inmates either.

“Everyone that’s in jail, they’re not perfect,” Rice said. “We assume they’ve made some type of bad decision. They still have a right to decent medical care. Someone was getting paid to give the prisoners decent medical care. And I don’t believe he got that.”

This story was produced by the Kentucky Center for Investigative Reporting, a nonprofit news organization. Reporter R.G. Dunlop can be reached at rdunlop@kycir.org or (502) 814.6533.