Features » December 8, 2009

Death by Privatization (cont’d)

Understaffed to death

“Low staffing levels put Ellis in a position of not getting what she needed,” Valerio says. “It frequently happens, but usually no one dies.”

PHS’s $16.4 million per year contract allows it to staff Northwest and other facilities on weekends (and many weekday shifts) with no one above the level of LPN. One PHS doctor is on call, by phone, to cover the 1,600 beds and the 7,000-8,000 people who annually transit the state’s eight jails. Leppman says he fields 20 to 30 calls a weekend. Nurses can work 12-hour shifts, and one says she was ordered to work 36 hours straight because no one else was available.

PHS’s contract allows all but one prison to substitute an LPN “without penalty if an RN is not available.”

The substitution is not trivial. Paid less, LPNs are also less trained (typically one year), and it is not clear, says Valerio, “that an LPN would know that it would have been life threatening” to delay potassium. Lorene Gendron, who worked for PHS for two years as an inmate advocate, says that poor support, salaries and working conditions mean high turnover. “They will hire any friggin’ warm body because they go through staff so much,” she says.

“PHS’s reputation is so bad that good people don’t want to work with them, or stay,” says Martha Israel, an RN who says she quit the women’s prison after “PHS hired an LPN to be nurse manager, a position requiring making patient assessments regularly, but I thought that was incredibly unsafe – and illegal.” When PHS’s contract was up for renewal, she tried to warn the DOC.

Timely treatment was a perennial problem. Dr. Charles Gluck, now retired, said that when he worked for PHS, he was frustrated by common delays in getting meds and X-rays.

One RN risked her career to fill the gap. In 2006 her patient was in pain, but the prescribed Tylenol 3 would not arrive for days. She violated the rules by taking Tylenol 3 a released prisoner had left behind, and giving it to the suffering woman. “I did the wrong thing legally,” she said, “but I was trying to do what was right for my patient.” PHS fired her.

“When I heard about Ashley’s death, and the failure to provide meds,” she said, “I thought: ‘Here we go again.’ They don’t have enough staff, so they push people to the ultimate. I’ll bet a dollar to a dime that’s what happened to the LPN on the weekend Ellis died.”

When Vermont first hired PHS in 2005, the contract mandated an inmate advocate to visit the prisons and field grievances. “I would say, ‘Why can’t you just give the patient the med they need?’” Gendron asked. “And PHS would say, ‘It’s too expensive, or not on our formulary.’ It was hard to see something so simple to do for someone and not be able to get it done. There was so much pressure not to prescribe.”

“The fewer services they provide, the more money they make,” Lipschutz says.

People vs. profits

“I’m still reeling,” Andrew Pallito, DOC commissioner, says of Ellis’s death. “Up until that point, they [PHS] were doing satisfactory work.”

In fact, from January 2008 to May 2009 (three month before Ellis died), PHS reported 169 sick call and pharmacy violations, and DOC imposed $19,200 in penalties.

Despite deaths, the blistering New York Times exposé, and warnings by nurses and others, Vermont renewed PHS’s contract for 2007. It let PHS cut twenty nursing shifts a week at Northwest, alter its contract to use LPNs rather than RNs as clinical coordinators and cut the inmate advocate position. Asked if money was the reason, Gendron, who earned $14 an hour, says, “I’ll never be sure.”

Much of PHS’s performance is self-reported, and state monitoring relies on limited resources as well as good intentions. Almost five years ago, Pallito was DOC management executive when an auditor’s report on CMS found that Vermont had no real way to evaluate the quality of care. “We didn’t belly up to the bar to monitor them,” he says. “I think we have made some improvements.”

Now DOC head, Pallito called Ellis’s death “an isolated incident. …[PHS has] been in Vermont for four years. On balance, it was not bad.”

Bad or not, PHS is exiting the revolving door and Correct Care Solutions (CCS) is entering. They have much in common. Both, are for-profit providers, and both have shared the same CEO, Gerald (Jerry) Boyle.

Before founding CCS in 2003, Boyle headed PHS from 1998 to 2003, a period covered by the Times investigation that found PHS medical care “around the nation has provoked criticism from judges and sheriffs, lawsuits from inmates’ families and whistle-blowers, and condemnations by federal, state and local authorities.”

Boyle’s Vermont connection goes back further. He was also a vice-president with EMSA when it was the state’s first prison healthcare contractor.

Negotiations between Vermont and CCS are in the final stage, and it is likely that the new contractor will retain many of the same staff and, unless Vermont writes a very different contract, a tradition of medical lapses and lax oversight.

Gipe is hoping that inquiries into her granddaughter’s death will spur reform. But if the investigation is confined to finger-pointing and narrow facts, the answers may obscure rather than reveal the extent and causes of a systemic breakdown that was remarkable for its tragic outcome rather than its particular errors.

Vermont, along with many other states, will still have to resolve the contradiction between the healthcare needs of an often despised population, and the demands of a private contractor for profit. In the latter, at least, PHS was successful: Healthcare revenues from continuing contracts for the third quarter of 2009 – the quarter when Ellis died from lack of a $4 bottle of pills – increased almost 28 percent over that quarter in 2008, to $160 million.