Tuberculosis tests take time.
First, there's the initial injection when the patient is shot with a small dose of tuberculin solution. Then, there's the 48- to 72-hour waiting period. Finally, the moment of truth: If the flesh around the syringe prick turns reddish and hard, the test is positive. If the skin appears normal, the patient is home free. A week later, the entire routine is repeated.
Inmates in New Mexico's correctional facilities are regularly administered two-step tuberculosis tests because one missed case can morph into a dangerous situation. This is a disease that runs particularly rampant in close quarters: homeless shelters, refugee camps, prisons.
In late 2005, Dr. Gayla Herbel, then the regional medical director for New Mexico's prisons, says she noticed that inmates' tuberculosis tests seemed to be coming back from the nursing staff too quickly and in too large a volume.
One afternoon, Herbel says, she randomly chose an inmate whose files indicated he’d tested negative for the disease. According to Herbel, the inmate told her he’d been injected with tuberculin solution, but no one had ever examined him after to read the results of the test. When Herbel reviewed the inmate’s medical charts, she found he’d actually been treated for tuberculosis within the past six months. Herbel says she subsequently discovered the files of an additional “handful” of inmates who’d never been properly tested.
"'If this truly is falsification of the tuberculosis testing and it is the norm, we are at risk for an outbreak,'" she recalls telling a colleague.
An endocrinologist by trade, Herbel says she alerted her employer: Wexford Health Sources. Wexford, a private, for-profit company, administers health care in nine New Mexico correctional facilities that house state prisoners and was Herbel's employer. Based in Pennsylvania, Wexford has handled prison health care in New Mexico ever since signing an approximately $27 million contract with the New Mexico Corrections Department in July 2004.
Herbel says Wexford never fully addressed her concerns and placed her on leave when she pressed the matter. She says she was offered the opportunity to return in a lesser capacity but, instead, quit a month after she first noticed the files-approximately eight months after she began the job.
SFR has no way to verify Herbel's story, but it is similar to the accounts of five other former Wexford employees interviewed over the course of a month-long investigation.
Among their allegations, the ex-employees say Wexford staff improperly doled out prescription drugs to inmates; canceled inmates' medical appointments because of staff shortages; and, to save money, failed to send sick inmates off-site to hospitals expeditiously.
Wexford, when contacted by SFR, requested all questions in writing and provided a written response to the allegations made by its former employees.
In that response, Wexford Vice President Elaine Gedman categorically denies most of the allegations, although she acknowledges past problems with tuberculosis record keeping that have since been corrected. Gedman also points to numerous successful audits of Wexford’s New Mexico operation by national correctional health care organizations.
"We are very proud of the service we are providing in New Mexico," Gedman writes. "We believe the best indicator that the services we are providing are appropriate is for you to consider the results from two external, independent organizations that have audited our services 13 times since May of 2005."
Wexford, according to the New Mexico Corrections Department (NMCD), has indeed been audited successfully by the American Correctional Association and the National Commission on Correctional Health Care. But SFR's review of Wexford's history also shows lost contracts and critical reports, some of which include findings similar to these latest allegations made in New Mexico.
SFR also has learned that the State Board of Nursing is currently investigating Herbel's allegations regarding the TB tests. Further, according to a September, 2005, letter written by Corrections Secretary Joe Williams, Wexford proposed paying the state approximately $35,000 to address state concerns about a shortage of hours worked by Wexford personnel.
Says Herbel: "Wexford management made it clear that it was not all about the quality of health care. It was about keeping down the cost and making up for money previously spent. There were cases where I believe that care of inmates was compromised."
Wexford won New Mexico’s contract at a time when the state was looking to save money. In fact, Gov. Bill Richardson’s “Save Smart” initiative, launched in 2003, specifically identified state corrections as a primary focus.
In 2004, Wexford, the third largest private correctional health company in the country, successfully bid to provide health care for the state's approximately 6,200 inmates.
Shortly thereafter, Richardson’s office issued an Aug. 12 press release touting a projected $7.2 million over four years in savings for inmate medical costs and vowing that the quality of care would be maintained or improved.
"We use a point system for bidders, and Wexford had the most points. They really stood out more than the other companies bidding," Devendra Singh, NMCD's quality assurance manager for health services and a member of the committee that recommended Wexford, says.
Among those companies was Addus Healthcare, which held the contract previously for two years. Company Vice President and Chief Operating Officer Mark Heaney says he was consistently told by corrections officials that his company was doing a good job.
"We're proud to say that the quality and responsiveness in our health care was excellent," Heaney says. "But the state was looking to save money, and we did not agree that we could deliver the services at a lower rate."
The same year Wexford won the New Mexico bid, it also unseated Addus in Illinois, where the latter provided health care in seven correctional facilities.
Despite Wexford's success in New Mexico and Illinois, the company has a well-documented history of problems.
In the late 1990s, the US Justice Department launched an investigation of the Wyoming State Penitentiary, where Wexford provided health care to inmates. Following the investigation, the Justice Department released a report that criticized, among other things, the staffing, medication and chronic illness management at the facility. It concluded that the lack of sufficient health care, along with other inadequacies, created conditions that violated inmates’ constitutional rights. Shortly after the Justice Department’s report, Wexford lost its contract with the state.
A 1998 press release also notes that the state's new contract with Correctional Medical Services includes "increased staffing and more stringent enforcement provisions for service delivery."
Wexford encountered similar problems in Florida. In that state, the Office of Program Policy Analysis and Government Accountability (OPPAGA), an arm of the Florida Legislature, issued a critical 2004 report on Wexford's operations.
The Florida Department of Corrections initially contracted with Wexford in July 2001 with expectations the company would save the state approximately $24.6 million over four years. According to the OPPAGA report, however, Wexford kept costs down by compromising the care of its inmates. Specifically, the OPPAGA report cites record keeping, insufficient staffing and the postponement of specialty clinic visits as the most pressing problems.
"There were concerns about the adequacy of care provided under the contract with Wexford," Kathy McGuire, OPPAGA's deputy director, says. "There were repeated incidents of non-compliance. Wexford would be notified, they would make a response, but the problems would re-emerge. It was frustrating."
The OPPAGA report was released in August 2004, the same month Richardson's office touted the expected savings from its new relationship with Wexford.
Singh says he was unaware of Wexford’s problems in Wyoming and Florida, but that during the bidding process NMCD randomly called various corrections departments where Wexford worked and heard mostly high praise for the company. Singh does not know if officials from Wyoming or Florida were ever contacted.
Wexford Vice President Elaine Gedman notes in an e-mail to SFR that the Justice Department report on Wyoming covered much more than health care services. She maintains that the state was "very satisfied with the way in which we operated in a very difficult situation after an inmate there murdered a security officer."
Gedman also writes that Wexford resolved all the OPPAGA issues that document raised and reported as much to the Florida Department of Corrections and the State Legislature.
“These entities were satisfied that we resolved all the issues that were raised,” Gedman writes.
Wexford has, from the start, saved New Mexico money. A review of the Save Smart initiative by the Legislative Finance Committee last April showed that of the 77 state agencies that successfully trimmed budgets, the Corrections Department was the most frugal. Of $3.7 million in total state savings, Corrections accounted for $1.9 million-more than half. Of that figure, savings for inmate medical services made up $1.3 million.
Some of Wexford's former employees, however, allege those savings came at too high a cost.
Angela Billings, a tough-talking woman of 43, served as a military police officer in the Army for 10 years before going into nursing. Wanting to combine her law enforcement experience with her medical training, Billings thought correctional health care the perfect fit for a second career.
In 1999, she was assigned to the Central New Mexico Correctional Facility at Los Lunas, the medical intake center for the state prison system. Each of the state’s approximately 6,200 inmates pass through Central for a comprehensive diagnostic and psychiatric exam, and the facility also holds the state’s only prison hospital, long-term care and geriatric units.
Billings worked for two years at Central under Addus, a company she believes treated both employees and inmates fairly. When Wexford took over, she says, things changed dramatically.
To start with, Billings says, under Addus, there were roughly two nurses for every 37 inmates. According to Billings, Wexford cut that ratio down to one nurse. Staff became so scarce at Central, Billings says, that "sick calls" and "med lines," during which inmates are seen for medical problems and receive prescription drugs, were sometimes cancelled because there wasn't enough staff.
Billings says she also noticed a difference in the clearance process for inmates' off-site visits to hospitals and specialists. According to Billings, Addus gave doctors and nurses discretion to decide when an inmate required specialized medial attention. Wexford, on the other hand, consistently denied approval.
"You were always being told that everything cost too much money," she says. "But these are people's lives you're talking about. Inmates were suffering all the time and it was really disturbing to see them not taken care of."
Billings also says she observed Wexford administrators at Central altering inmates' medical records.
"They were hiding mistakes they'd made," she says.
Linda Martinez, an ex-administrative assistant at Lea County Detention Center in Hobbs, and Burt Patterson, a former nurse at the Roswell Correctional Center, echo many of Billings' concerns.
Martinez, a seven-year veteran of correctional health care, worked for CMS and Addus before Wexford. She says Wexford was so insistent on saving money it would deny doctors’ requests for medical supplies. Staffing was so short that a Wexford administrator once authorized a lab technician to start an intravenous flow on an inmate, something he was not legally licensed to do, she says.
Like Billings, Martinez was bothered most by the amount of time chronically ill inmates waited for off-site medical treatment.
"Our inmates stayed in pain a lot," Martinez says.
Patterson, who also worked under CMS and Addus, agrees that the most glaring difference with Wexford was the company's cost cutting.
"Under Addus, if an inmate needed something, well then, they needed it, and Addus helped them," Patterson, who currently works for a correctional health care management firm in Colorado, says. "With Wexford, it was always the money. We had to wait until an inmate was practically dying before we could send them off for X-rays."
Patterson eventually quit Wexford in July, 2005, in part, she says, because of her concerns. Billings and Martinez were fired by Wexford within the last year. Both women say they were terminated because they clashed with their bosses over, among other things, the adequate administration of health care.
In a letter to SFR, Gedman refutes all of the allegations made by Billings, Martinez and Patterson. The former employees were not identified, by name, to Wexford in SFR's written questions; Wexford's response notes: "We are understandably concerned that these questions appear to be coming from disgruntled former Wexford employees who seem to have some sort of axe to grind against Wexford and/or the New Mexico Department of Corrections."
Specifically, Gedman says the ex-nurses' assertions that Wexford delayed sending sick inmates off-site to cut costs is "absolutely untrue."
“Wexford prides itself on its physician-driven model which ensures that doctors make the decision to treat a patient at the appropriate place of care, whether on or off site,” Gedman writes. “Wexford believes identifying and treating a medical need earlier, rather than later, leads to the highest quality service and in the long run lowest cost alternative; regardless of place or cost or the service.”
Gedman also denies there is inadequate staffing.
“Wexford’s staffing levels are constantly reviewed and monitored to ensure that appropriate service levels are maintained. Our turnover ratios are similar to the healthcare industry as a whole. Wexford continues to actively recruit for qualified staff for positions at all of our locations.”
Other Wexford ex-employees have raised additional concerns. Jennifer Hand began working as Wexford's regional consulting pharmacist in July 2005. She oversaw the prescription drug distribution system, inspected medication rooms and reviewed patient records to ensure the appropriate use of medications. A few months into her job, Hand says she started noticing widespread problems.
According to Hand, she caught a nurse filling a baggie with a 30-day supply of the acid-reflux drug Zantac from a stock supply after the inmate's individual prescription had run out.
One nurse, Hand says, admitted to her dispensing insulin from one diabetic inmate's prescription to another inmate whose prescription had run out in order to save money. Other nurses, she says, administered psychotropic medications to inmates even after the physicians' orders had expired, instead of obtaining renewals.
Overall, Hand says Wexford's record keeping was so desultory, it was difficult to keep track of which inmate was getting which medicine. When she repeatedly informed Wexford's chief health services administrator in New Mexico, Hand says she was roundly ignored.
"Inmates were hoarding doses and using them as currency [because] nursing staff were not adequately controlling medication dosage," she says. "The nurses who did this were exceeding the scope of their licenses, breaking the law and jeopardizing patient safety."
Regarding allegations that nurses illegally dispensed medications, Wexford's Gedman writes: "We are not aware of this taking place."
In January, Hand was fired; she says it was because she was barking too loud.
Shortly after leaving, Hand met with a team of state pharmacy investigators about her allegations. Board of Pharmacy Director Bill Harvey says that following Hand’s initial contact, his agency conducted a routine review of the state prison pharmacies but found no “major violations.”
Hand says she plans to file a formal complaint with the Board of Pharmacy in the coming weeks.
Larry Brown, who has been a nurse at various correctional facilities, psychiatric hospitals and jails over a 24-year career, became Wexford's director of nursing at Central in January 2005.
Almost immediately, Brown says, he noticed "glaring errors" in how Wexford staff kept medical charts. He says inmates received the wrong medicine, even the wrong dosages. In one instance, Brown says an inmate with an infection in one eye was refused access to a specialist for six weeks.
Brown says his complaints to Wexford fell on deaf ears. "There was no cleaning up this mess," Brown says. "They were cutting corners and saying, 'Let's not worry about it.' It was putting inmates' health in jeopardy."
Brown also confirms Dr. Gayla Herbel's story of the botched tuberculosis tests; he was one of the medical staff Herbel first told and helped her sift through records that winter night.
Like Herbel, Brown alerted Wexford administrators in New Mexico. When Herbel was placed on leave, Brown quit, one month after taking the job.
Brown shakes his head as he recalls his brief time with Wexford.
"I have a license. I'm not going to lose it over shenanigans. It's not happening," Brown says.
Regarding tuberculosis testing, Wexford’s Gedman writes: “Wexford learned of a problem with record keeping regarding certain TB tests performed. Upon learning of the problem, we immediately took corrective action and ensured that the appropriate care and follow up was delivered and the problem was resolved.”
In May, Brown filed a formal complaint with the New Mexico Board of Nursing regarding the tuberculosis tests. Michaeline Kelley-Boyet, the agency's nurse investigator, tells SFR that she is currently investigating the complaint. Kelley-Boyet says the Board of Nursing is in the process of subpoenaing medical records from Wexford and will be interviewing Wexford employees in the coming months.
On an unseasonably humid day in Los Lunas, a team of correctional experts leads this reporter on a tour of Central New Mexico Correctional Facility’s medical complex.
The team includes Dr. Tom Lundquist, chief medical officer for all of Wexford's operations; Erma Sedillo, NMCD's deputy secretary of operations; and Devendra Singh, NMCD's quality assurance manager for health services.
Singh, a jovial man who jokes that he has more energy now than when he started with NMCD 26 years ago, chats away as he guides the group through Central's labyrinth of rooms and hallways.
Currently, Singh is filling in for Dr. Frank Pullara, NMCD's health services director. Pullara, who has been on medical leave since February, was directly responsible for assessing Wexford's medical care. When contacted by SFR, he deferred all questions to Singh. Singh says he's licensed to practice medicine in India but not in the US; therefore, he can only monitor Wexford's administrative procedures and has no oversight over its clinical performance. That oversight is temporarily up to Wexford, Singh says-at least until NMCD hires a new medical director. That hire should come soon, according to spokeswoman Tia Bland.
Nonetheless, Singh says he is unaware of any problems with the company's performance in New Mexico, and NMCD assiduously monitors Wexford through a quarterly system of site visits and records reviews.
"Through our auditing process, we have found they are doing a satisfactory job," Singh says.
Regarding allegations about systemic staffing deficiencies, Singh says that it would have been difficult for Wexford to earn its accreditation from the American Correctional Association and the National Commission on Correctional Health Care if such gaping shortages truly existed. He does, however, acknowledge that hiring and retaining medical staff in the prisons is a challenge.
“In our line of work, this is our biggest battle. You could ask God to come down and sign a contract to run the health care, and he would have problems finding staff,” Singh says. “Wexford has spent a lot of money out of their own pocket to make sure we have enough staff. That’s how I’m able to sleep at night. I’m not completely satisfied, but I’m satisfied that they have satisfactory staffing on a daily basis.”
It's difficult to assess the validity of the state and Wexford's assurances of adequate staffing. On July 12, SFR filed a formal written request to the state for a list of all Wexford staff working in New Mexico. At first, spokeswoman Bland informed SFR that NMCD had no such record. Bland then told SFR she would try to track down such a list. Shortly thereafter, this reporter received a phone message from Bland that suggested SFR obtain that list from Wexford.
"We're currently in the process of working with Wexford in getting a monthly report from them on their staffing," Bland said in the message. "Before Dr. Pullara went on medical leave, he had been talking with Wexford about some issues concerning staffing at various facilities. We are not altogether clear at this point as to what agreements he may have made with them verbally. We are revamping the monitoring process for that."
Per Bland's suggestion, SFR requested a list of all Wexford staff and their positions in New Mexico from Wexford. Gedman initially responded that Wexford employs 210 individuals in New Mexico. When pressed for more information, Gedman e-mailed a list of medical positions that Wexford utilizes ranging from administrative assistant to X-ray technician. When SFR again asked Gedman for a list of individuals and their positions at each facility and noted that NMCD suggested Wexford maintained such a list, Gedman wrote back:
"As for providing a list of names for Wexford employees, we view that as personal and confidential information, which we are not willing to provide."
Singh says he checks Wexford's payroll to ensure each facility has enough medical staff and that he's working on getting Wexford to provide regular staffing records to NMCD. Singh says he was unaware of a $35,000 payment agreement between Corrections Secretary Joe Williams and Wexford related to staffing issues last fall.
In a Sept. 23, 2005 letter, Williams writes of his "very serious concerns that Wexford was not providing the number of work hours or FTEs [full-time employees] required by the contract for its personnel, particularly its psychiatrists." That letter indicates the payment was proposed by Wexford in response to state concerns about understaffing, and says that Wexford "proposed several detailed staffing changes to the current staffing pattern in an attempt to prevent any similar problems in the future."
SFR was told by Tia Bland that Williams was unavailable for an interview.
Singh also says Wexford's process for approving off-site visits-known as "collegial review"-is the best system he's seen. Collegial review entails Wexford physicians discussing the details of individual cases, without any corporate input, and then making a collective decision on how to proceed.
Again, it's difficult to evaluate the company's collegial review process. On July 12, SFR requested in writing from NMCD a record of the total number of off-site medical referrals granted by both Wexford and its predecessor, Addus. NMCD responded, in writing, that the department has no such records. SFR re-requested the information in a July 27 e-mail. On Aug. 7, following a telephone conversation with
Bland, SFR received an e-mail from Bland stating that off-site referrals, over the last six months, included: 439 hospital days; 1,251 out-patient appointments; and 147 inmate emergency room trips.
Regarding the tuberculosis tests, Singh also seconds Wexford's assessment that all problems have been remedied. He says that the inmate Gayla Herbel refers to in her account did not speak English and had difficulty communicating with nursing staff, which caused confusion to the status of his test. Singh couldn't confirm Herbel's statement that the inmate was previously treated for tuberculosis. He points out that the inmate ultimately tested negative for the disease.
"We are very strict on TB tests. I am a stickler. TB testing is at the top of my list," Singh says. "We don't have inmates who are running around with [tuberculosis]. I'll bet my job on it."
Despite NMCD and Wexford’s assurances, private correctional health care companies have faced numerous problems around the country.
“It has become a merry-go-round. One company promises a lot, gets a government contract and does not perform well and so the government hires another contractor,” Elizabeth Alexander, director of the ACLU’s National Prison Project, says. “States think that going to a private contractor will save them money. Instead, it turns into a nightmare.”
State Sen. Cisco McSorley, D-Bernalillo, co-chairman of the State Legislature’s Courts, Corrections and Justice Committee, believes private medical services in New Mexico’s prisons is the wrong approach.
"Obviously, the system is broken," McSorely says. "Appropriate medical care is not being provided to state prisoners, and we've discussed this in various legislative committees. But nothing has been done from the executive branch through two different administrations other than to keep privatizing the services."
Elizabeth Alexander points to last year's New York Times exposé on Prison Health Services (PHS), a private company that has provided health care in New York correctional facilities. The Times story reveals how PHS managed to obtain lucrative contracts in New York with promises of cheaper costs and better care, despite warnings from ex-medical staff, critical reports on the company and a rash of inmate deaths.
PHS is one of Wexford's main competitors.
Says Alexander: “Not every time you do something wrong will bad things happen. But if you play the odds long enough, eventually, it will result in disaster.”
