Arizona researchers try to figure out how to prevent stress-related pain.
On The Inside: The Chaos Of Arizona Prison Health Care
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, inmates 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. Inmates 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, the phone rang.
“He has a really a 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 to 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 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 Monday 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.
“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. There 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.”
Slideshow: Inmate Cases Alleging Improper Care
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 inmates 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 inmates 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 their 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 inmates with chronic illness is 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 settlement.
“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 cell mates 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.
“I want to believe that it’s going to bring about change – that the federal government and the state government is 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 inmates 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.
The Arizona Department of Corrections and Corizon Health have not responded to the allegations filed in federal court Monday afternoon.
D r. 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.”
Watson invited KJZZ to her dining room table for this interview because she wants the public to know what’s happening inside Arizona prisons. After presenting the Arizona Department of Corrections with Watson’s allegations ADC said in a statement: “The Arizona Department of Corrections expects its current contracted health care provider, Corizon, to provide all inmates the constitutionally-mandated health care to which they are entitled. Furthermore, ADC expects Corizon to promptly address the serious allegations you emailed that were made by Ms. Watson.” After conducting an investigation into Watson’s allegations, Corizon’s attorney provided KJZZ with the responses printed in this article via email.
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, she got an 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 she was told she’d be given a week of training from the Arizona Department of Corrections (ADC) 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 inmates.
Watson says the pace was overwhelming.
“They would schedule 20 patients for you daily for multiple medical problems.”
She says she frequently treated inmates 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 inmates 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 shortages of providers was significant. In his request for overtime workers, a Corizon employee notes that in October there were more than 800 outstanding requests for medical treatment.
Watson says getting medicine for inmates was a constant challenge. “There were several inmates who had cancer and so they were taking morphine,” Watson said. She says 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 inmates 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 an inmate 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 an inmate 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 inmate 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 inmate from hurting himself.
“‘Oh, ‘Well, we’ll order a helmet for him to protect his head,’’” Waton 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 cancelled from July 1, 2017, through the end of September, 2017.
“Eighteen appointments were canceled, and of those, 12 of them were cancelled 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 cancelled 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 an inmate. “He was known to have heart disease.”
His symptoms, combined with an EKG, made Watson think he was having a heart attack, but she says couldn’t get approval to go to the hospital for hours.
After the referral was finally approved, Watson’s fears were confirmed. The inmate had suffered a heart attack.
Watsons says her medical director, Dr. Rodney Stewart, reviewed the inmate’s test results from the hospital and conveyed the treatment plan to her and the inmate.
“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 inmates medical record and looked at the notes from the hospital. She says what she saw conflicted with 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 stint.”
Watson created a new plan. She prescribed the inmate 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 inmate’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, Jan 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 their 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 inmates. 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.”