In mid-March 2002, Marcella N. Leski, 39, was jailed for failing to appear in court on a drug-possession charge. Twelve days later, she was so ill that her legs were amputated below the knees.
Her family alleges in a lawsuit that the prison contractor's doctor failed to diagnose and treat an infection that can be cured with antibiotics.
While the question of legal responsibility is in dispute, what is not in question is that Leski's condition deteriorated while she was in the custody of the state-run Baltimore Women's Detention Center.
Maryland's prisons are no place to get sick. The state's own audits and correctional system records show that the prison health care system has been underfunded, understaffed and poorly run.
A Sun investigation found that many inmates over the past five years have received inadequate medical attention, according to interviews, independent state audits, internal state records and other documents.
Maryland corrections officials acknowledge underfunding and providing spotty oversight of the state's main medical contractor, Tennessee-based Prison Health Service Inc.
"We believe [health care] was constitutionally adequate," said Richard Rosenblatt, who oversees medical care for the Department of Public Safety and Correctional Services. "But it was not the type of health care we felt we should be delivering."
Prison Health executives say they provided appropriate care to inmates, including Leski, despite rapidly escalating health care costs and a contract the company signed in 2000 that turned out to be a money-loser.
As of June 30, Prison Health, one of the nation's largest for-profit correctional health care providers, will no longer be providing inmate health services in Maryland. Its contract expires on that date, and the state recently selected other vendors to provide services for the state's 27,000 inmates in a totally restructured system.
Over the next fiscal year, the state expects to pay roughly 60 percent more for inmate health care services - or $110 million compared with $68 million spent last year.
But some prisoner advocates say they doubt that the situation will improve despite the additional money and change in contractors. They say profit motives will continue to influence the quality of care that prisoners receive.
While Rosenblatt acknowledges that there have been problems, he says he is confident that the introduction of the revamped and better-funded system, using the new vendors, on July 1, will solve them.
Prison Health executives say they pleaded to get out of the contract two years ago but the state refused, and that Maryland continued to pay far less for services than it was costing Prison Health to deliver. The company says it was paid more than $260 million in Maryland over the past five years, but lost $14 million.
"What you can say is that, in retrospect, it was a bad business decision," said Richard D. Wright, who until March 31 was Prison Health's president and chief executive. He is now a consultant to the company and was designated to speak about its dealings with Maryland.
A grim picture
State audits, lawsuits, internal memos and other documents reveal a grim picture of inmate heath care since 2000, when Prison Health got its contract.
The problems include:
Insufficient staffing. Staff shortages have caused lengthy delays in prisoners being seen by physicians, psychiatrists and nurses, according to audits of prison infirmaries done by the state Office of Health Care Quality, an independent state agency that monitors health care facilities in Maryland.
Baltimore's jails, the Central Booking and Intake Center and the city detention center, could provide psychiatrists for only 100 of the 156 hours required each week last year, according to a Sun review of staffing records. During this period, the facilities had five inmate suicides - the highest in seven years, records show. The previous year there were two.
Poor medical record-keeping that interfered with the delivery of care. State auditors found several examples of the problem at different prisons.
On a March 2002 visit to the infirmary at the Maryland House of Correction in Jessup "it was observed that one inmate had been in a bed on the unit for more than 15 hours," auditors from the state health care quality office wrote. "There was no admission order, transfer note, vital signs, history, initial nursing assessment, documentation of nursing protocols or any treatment/care plan. Interviews with the nursing staff on the unit revealed that there was no information on the inmate."
And records that are kept are not always reliable. For example, state corrections officials discovered in March that Prison Health staff members apparently had altered records to falsely indicate that they had conducted required checks on suicidal inmates every 15 minutes at the Women's Detention Center in Baltimore, according to e-mail between state and Prison Health officials. The employees involved resigned, Prison Health executives said.
Failure to examine closely enough and follow through on inmate medical complaints.
For example, Ricky Scearce, 48, reported in 2001 all the classic signs for colon cancer to a prison doctor on the Eastern Shore, according to a lawsuit he filed against Prison Health. Although his symptoms persisted, no colonoscopy was ordered to test for the disease until two years later, as Scearce's release date approached, the lawsuit said. The diagnosis then: advanced-stage, terminal colo-rectal cancer. Prison Health settled the lawsuit last year for an undisclosed sum and declined to discuss Scearce's case.
During visits to the Maryland House of Correction in Jessup in April and May of last year, state auditors found that Prison Health medical staffers were not responding to inmate requests within three days, and that urgent medical conditions were not being consistently evaluated within two days.
"The present process used by the nursing staff demonstrated lack of thoroughness, follow-up and time-setting for sick-call appointments based on medical triage," the auditors wrote.
Frequent delays and mix-ups in getting medications such as insulin, asthma medicine and AIDS drugs to inmates who depend on them, exacerbating health problems. This was a chronic problem, according to independent state audits, internal documents, and complaints by inmates and advocates.
Public Safety Secretary Mary Ann Saar conceded the problem when she told a community organization in December that the department could not implement a methadone maintenance program for inmates at the Baltimore jail because it was already having problems getting standard prescriptions to inmates.
"We have repeatedly heard complaints relating to the failure of inmates to receive medications ... in a timely manner," Saar wrote.
The problems of drug delivery were also the subject of internal discussions among Prison Health's staff in Baltimore. At a Feb. 13, 2003, meeting, Prison Health's nursing managers complained that critical documents that doctors and nurses rely on to track drugs given to inmate patients were "not being completed properly," according to minutes of the meeting.
'A difficult environment'
In interviews this year, Prison Health executives insisted that they met their obligations and did not cut corners on care - despite losing millions on the Maryland contract. They said the audits reflect occasional mistakes they worked to correct, not deliberate neglect.
"I accept an audit, a criticism that the system isn't what it could be," said Wright, the Prison Health consultant. "What I reject is that there is any intent on anybody's part to not give every single patient what they need, when they need it."
Wright noted that only four of the 148 lawsuits filed against Prison Health in Maryland since 2000 have resulted in financial settlements. And the total paid to settle those four claims was less than $1 million, he said. Of the remaining lawsuits, 116 were either dismissed, closed or dropped, and 28 remain open, Wright said.
He said Prison Health works hard to "have outcomes that are appropriate and desirable ... but it's a difficult environment and it's a difficult group of patients."
Wright noted that the company treats patients who tend to be sicker than the general population. Many inmates have a combination of problems, including drug and alcohol addiction, chronic illness and infectious disease, he said.
"It is a tough group," he said.
Many of the problems in the inmate health care system are rooted in the way the company's contract with the state was structured. Under that contract, Prison Health was responsible for providing comprehensive health care services to more than 20,000 inmates across Maryland, except for three prisons in Hagerstown.
The company bid what was essentially a flat fee to provide a broad array of services - medical and dental care, mental health services and pharmaceuticals. Industry analysts say such "fixed-rate" contracts were more common at the time but are no longer sought by companies because of the financial risks.
Prison Health's experience in Maryland illustrates the risks. Soon after it signed the contract, the rate of medical inflation began to soar. The company found itself locked into a long-term agreement that was not generating enough money to cover escalating costs, according to Prison Health officials and corporate filings.
One major factor driving up costs was the price of medications, especially expensive new drugs to treat prisoners with AIDS. The costs averaged $667,000 a month in 2000; this year, costs are averaging $936,000 a month, Wright said.
He said AIDS medications account for just under half of the $11.2 million that Prison Health expects to spend on drugs for the fiscal year that ends June 30.
In addition, hospitalization costs more than doubled, from an average of $413,000 a month in the first year of Prison Health's contract to $860,000 over the past year, according to Wright.
But what turned out to be a bad deal for Prison Health was a good one for the state, at least in financial terms. One of the few detailed analyses done by the state showed that Maryland was spending $2,293 per inmate on health care in 2002 - well below the national average of $2,722.
"Most of the states at that level are poor states, like Alabama and Mississippi," said Elizabeth Alexander, director of the ACLU's National Prison Project. "I think it should bother the citizens of Maryland to be in that category."
She noted that Maryland is a wealthy state.
The ACLU is a lead plaintiff in a civil rights lawsuit alleging poor health care services and deplorable living conditions at the state-run Baltimore jail facilities.
As costs rose much faster than Prison Health had projected, the company pleaded to be released from the contract at the end of three years. But the state exercised its option to extend the contract for two years. Alexander and other critics say that decision ultimately compromised inmate health care.
Saar, the public safety secretary, refused interview requests but responded by e-mail to questions.
She wrote that the issue of extending Prison Health's contract came up soon after her appointment in early 2003. The contract was due to expire later that year, and there was not enough time to seek bids for a new one, she said.
Saar added that state budget analysts were urging her to move quickly to extend the contract by two years because "the state was paying far less than the cost of providing the services." After extending the agreement, she ordered staff to closely monitor Prison Health's performance, she said.
The ACLU's Alexander said state officials demonstrated a "lack of concern" for the welfare of inmates by extending the contract - even after serious problems with medical care at the Baltimore City Detention Center were highlighted in a highly critical U.S. Justice Department report in 2002.
Dr. Ronald Shansky, a nationally recognized expert on prison health care, said a state cannot be excused from its responsibility to deliver an appropriate level of health care services to inmates in its custody.
"If a contract is underfunded, and not just poorly managed, that's also a state responsibility," he said. "They should know what it takes per capita to provide the services ... and shouldn't support any bidder whose proposal is too low" to do the job properly.
Public health officials and advocates say providing proper medical care is important because inmates with tuberculosis, AIDS, hepatitis and other infectious diseases eventually end up back on the street, posing health risks to the communities they re-enter.
David Vlahov, director of urban epidemiologic studies at the New York Academy of Medicine and a professor at the Johns Hopkins University, said a prison stay can be an opportunity to reduce the transmission of infectious diseases.
"If you look at prisons, half the people get out in less than three years and they go back to the communities where they were before," Vlahov said. "Whatever health issues were not addressed in the prison setting come right back out into the community."
Baltimore's jail facilities, where most people who are held have not been convicted and are awaiting a court hearing or trial, have proven to be the toughest challenge for state corrections officials and Prison Health for the past five years.
The Central Booking and Intake Center on Madison Street, which now processes 100,000 people a year, has been consistently overcrowded since it opened 10 years ago. And the Baltimore City Detention Center next door, parts of which were built in the early 19th century, saw its average daily population climb last year to 3,161 - an increase of nearly 600 inmates since 2001.
Both facilities have been criticized for deplorable living conditions and overcrowding that contribute to the spread of illness and disease, according to reports by federal, state and local authorities, and inmates and human rights advocates.
Mice, rats and roaches infest the state-run city facilities; periodic sewage backups flood the floors; and antiquated heating and cooling systems keep the prisons smothering hot in summer and frigid in winter, according to independent state audits, health inspection reports and records filed in federal court.
During a visit to the Women's Detention Center on Jan. 23, 2004, inspectors with the state Office of Health Care Quality criticized the dilapidated conditions of the jail's mental health unit, where prisoners requiring close supervision are held:
"Inmates were found to tear apart the mattresses and climb inside of them to stay warm, and/or use some of the fiberfill material from the mattresses to cover the windows in an unsuccessful attempt to block out the cold air drafts from the outside," auditors wrote.
The inmates were ripping open mattresses and climbing inside because they were being held naked in cold temperatures, according to interviews with state corrections officials, Prison Health managers and former inmates. They even had a nickname for the cells: "the buck-naked room," according to former inmates who were interviewed.
Inmates were supposed to be given suicide smocks, but the specially designed outfits were often lost when they were sent out for laundering, said Dr. Annette Hanson, Prison Health's chief psychiatrist in Baltimore.
Hanson and state officials said they addressed the problem by ordering more suicide smocks, installing thermometers outside the cells and moving inmates when it got too cold.
Staffing was another daily challenge. Prison Health officials say they had trouble hiring and retaining staff because the state's prisons were perceived as dangerous and recruiting in the medical field was highly competitive.
Hanson and Wright said that was the reason the company was unable to satisfy an increase in required hours for psychiatrists in Baltimore last year. However, they say they don't believe the staffing issues contributed to the sharp increase in suicides at the jail last year.
They noted that Prison Health added other positions, such as social workers, and implemented improvements such as a pilot program that tracks repeat offenders with chronic mental health problems. They said the company provided more space for evaluations and greater collaboration with outside mental health providers.
"As part of our services, we have things that we've never had before in Baltimore," Hanson said.
But the stresses in Baltimore led to regular conflicts between state corrections officials and Prison Health. They clashed over staffing, performance and other issues, according to e-mail and other internal department documents obtained by The Sun.
In a May 2004 e-mail, Benjamin Brown, assistant commissioner for the Division of Pretrial Detention and Services, complained of continual disputes with Prison Health over staffing and how medical evaluations of new arrivals at the facilities would be conducted.
"Their cavalier attitude to their contractual and ethical responsibilities is unacceptable; their inability or unwillingness to communicate effectively is equally unacceptable," Brown wrote to a state corrections official who oversaw inmate medical services.
In one highly publicized case last year, Prison Health reprimanded and reassigned four employees who failed to perform their duties properly in the case of a female inmate who died Sept. 14 from an advanced case of cryptococcal meningitis.
Deborah Epifanio, 34, who had been held at the women's prison in Jessup and the women's jail in Baltimore, had experienced fainting spells for days before Prison Health staff sent her to an emergency room.
State corrections officials have not released additional details about the circumstances surrounding her death.
Prison Health had its own complaints about actions of correctional officers. In October, for instance, a Prison Health nurse wrote in an e-mail to her supervisor that she wasn't allowed to evaluate an inmate because a correctional officer thought the inmate was "faking" a problem.
As part of a civil rights lawsuit filed against the state, the American Civil Liberties Union and the Public Justice Center compiled statements and medical records from more than 100 inmates that, they say, illustrate terrible living conditions and poor medical care. The complaints include a lack of follow-up on inmate medical issues, long delays in mental health treatment, insufficient diagnostic testing and dangerous disruptions of inmates' prescription drugs.
In court filings, state officials responded that these cases do not demonstrate systemic deficiencies in medical care. The state also noted upgrades made, or planned, at city jail facilities, such as improvements in the ventilation system at the women's jail.
The new system
State corrections officials say they expect the new system for handling inmate health care to solve many problems once it takes effect July 1. The state has divided inmate health care into different categories of services and has hired multiple vendors, said Rosenblatt, the assistant public safety secretary responsible for treatment services.
Both Prison Health and its main rival, St. Louis-based Correctional Medical Services Inc., submitted bids for the medical service component, the largest of the contracts, with CMS winning. Prison Health's contract expires June 30.
CMS has held the contract for health care services for three prisons in Hagerstown since 2000.
The new system eliminates some of the major financial risks of a "flat-fee" contract such as that held by Prison Health, according to Rosenblatt. He said no private companies were willing to bid if Maryland offered another flat-fee contract.
After July 1, vendors will be reimbursed for certain expenses such as inmate hospital stays, so there will not be a financial incentive for the vendor to deny or delay hospital care, Rosen- blatt said.
A separate company, Wexford Health Sources Inc. of Pittsburgh, was chosen to manage and oversee the use of hospitalization and other care to keep costs in check, Rosenblatt said. He said the contract gives Wexford financial incentives to hold down costs.
"The more they can hold down costs, the more money they make," Rosenblatt said.
The new contracts set up stringent quality-control measures and greater accountability for sick call services provided to inmates. Another big change is that the system will be treating inmates infected with hepatitis C, a blood-borne liver disease that prison health experts say has become a serious issue in the nation's prisons.
Rosenblatt also noted that more money is being pumped into inmate health care to improve the system and beef up staffing, particularly at the Baltimore jail facilities.
Advocates for prisoners are skeptical of the state's contention that the new system will solve the problems. They say they would prefer that inmate health care be handled by the state, or by nonprofit teaching hospitals or other nonprofit organizations.
New provider criticized
Advocates also criticized the state's selection of CMS as the new medical provider. They say CMS has been criticized in news reports and lawsuits over quality of care issues in other states - allegations that CMS vigorously disputes.
"Lawsuits are allegations," said Ken Fields, a CMS spokesman. "More than 95 percent of those allegations were dismissed by the courts for a variety of reasons. CMS has a history of improving the quality of care and providing a valuable service to inmate patients and corrections agencies all across the country for over 25 years."
Wendy Hess, a staff attorney for the Public Justice Center, said the additional dollars the state plans to spend won't necessarily go toward improving inmate health care.
"You still have all the same for-profit incentives in terms of cutting costs, which means cutting the quality of care," she said.
The debate over the quality of care afforded to inmates aside, some say what is lacking in some cases is basic human compassion.
Marcella Leski's brother John said the way that she was treated was inexcusable.
"Any decent human being would say, 'Get her checked out,'" said Leski, a painting contractor from suburban Philadelphia.
A lawsuit filed by her family says that she was "deemed to be a malingerer" and given only an over-the-counter pain medication even though she was in excruciating pain and could barely walk.
The lawsuit alleges that a medical test that could have detected what was truly ailing Leski, an infection, was never done and that her condition worsened, forcing doctors to amputate her legs below the knees.
Prison Health and the doctor named in the lawsuit declined to discuss specifics of Leski's case. But in papers filed with the court, each denied allegations of negligence, wrongdoing or any breach of standards of medical care, and stated that no "acts or omissions" on their part led to her injuries.
The charges against Leski for failing to appear in court on drug possession and related charges were dropped as her health deteriorated. Several months later, she died of a staph infection in another hospital.