Editor’s Note
This is the final part of Gaming the System, Brian Sonenstein’s three-part series on the privatization of correctional healthcare. Read Part 1 & Part 2. -KO
The conduct of jail doctors working on behalf of medical contractor Advanced Correctional Healthcare is at the center of an ongoing federal civil rights lawsuit facing Dearborn County. Despite the fact that ACH touts its staff as being “correctional trained,” an examination of the records of their Doctors Nadir Al-Shami and Ronald Davis raise questions about the standards of care provided by the company, even though the company and the doctors are no longer named in the suit.
In 1994, California convicted Doctor Ronald Davis of the unauthorized practice of medicine after an undercover detective caught his unlicensed office assistant “examining, diagnosing, prescribing a method of treatment, and treating patients” at his private practice. His assistant was also found to have been illegally writing prescriptions for controlled substances.
Dr. Davis’ assistant was Martha Bice, also known as “Toni.” In some cases, patients reported they never actually saw Dr. Davis over the course of their treatment. They only met with Toni.
The Medical Board of California highlighted three cases in which Toni was found to have unlawfully provided care to patients: in July 1993, Toni examined and prescribed antibiotics to a girl named “Heather G.,” whose mother brought her to Dr. Davis’ office complaining of an ear infection. Toni saw and treated Heather on multiple occasions without Dr. Davis.
In October of that year, a woman named “Carla Y.” went to Dr. Davis’ office seeking treatment for an eye infection. Toni examined her and prescribed antibiotics, but when Carla arrived at the pharmacy to pick them up, she was so concerned about the severity of her infection she changed her mind and went straight to the emergency room.
Then, in the early fall of 1993, an undercover investigator for the California Medical Board named C.H. Conley visited Dr. Davis’ office after receiving an anonymous tip that his assistant had been seeing his patients. Adopting the name “Chuck Ray Coy,” Conley arrived at the office and told Toni he was suffering from back pain.
Toni told Conley the doctor wasn’t in, but she could examine him instead, and took him to a back room. After conducting an exam, Toni prescribed him codeine #4 (a controlled substance) and contacted the pharmacy to have it filled. She asked Conley if he needed anything else, and when he said no, she “pressed him by stating, ‘What about a vitamin shot or something.'”
Conley told Toni he really did not want a shot, but she gave one to him anyway; he was given a cortisone injection in the buttocks. Toni told him she didn’t want to inject him in his back because if she did it in the wrong place, it could paralyze him.
Conley returned to the doctor’s office a few days later and Toni again offered to examine him, as Dr. Davis was not in the office. This time, Conley said he would rather wait until the “other doctor” arrived. When he did, Conley told Dr. Davis that Toni “really fixed him up.” Davis agreed.
In subsequent interviews conducted by Conley, Dr. Davis admitted he knew Toni was seeing his patients and writing prescriptions for controlled substances. He also admitted he knew it was wrong. He apologized and offered to repay any money and make any restitution the board saw fit.
Timothy Strayer & the ‘circuit rider’
Timothy Strayer was sixty nine years old and suffered from serious chronic illnesses when he became an inmate at the Dearborn County Detention Center in 2011. After less than a month in the facility as a patient of ACH, Strayer would find his urgent medical complaints unmet and suffer a perforated ulcer before he was finally taken to the emergency room on August 3, 2011. He would spend nearly 200 days in hospitals and nursing homes recovering from multiple surgeries before going back to jail to serve his twelve month sentence.
Doctor Ronald Davis examined Strayer the day before when he filled in for Dearborn County Detention Center’s site physician Doctor Nadir Al-Shami. Both men were employees of Advanced Correctional Healthcare: a private company under contract with the jail to provide medical care to inmates.
In his deposition for Strayer’s lawsuit, Dr. Davis admitted he was not specially trained to care for inmates, but practiced general family medicine. He felt that meant he could tend to a “broad variety of medical problems.” Dr. Davis also said he was “seeing the same kind of problems” among inmates as he saw in general practice, although he conceded there may be “you know, some minor differences.”
Dr. Davis worked as a “circuit rider,” meaning he managed the care of hundreds of inmates at multiple jails. At the time of his deposition, he claimed to be the site physician for four jails, but said he had been previously assigned to as many as seven or eight at a time. Dr. Davis’ jails were located anywhere from thirty minutes to three hours away from his house. In some cases, they were even further away.
He would get calls from his jails about five to ten times a day. They were mostly questions about health issues and medications, sometimes for new inmates. Davis said if he couldn’t address a problem over the phone and felt it was urgent, he would have the inmate sent to the hospital — a decision in which the jail’s nurses (or in the case of Dearborn County Jail, the unlicensed assistant, Kelly Hogg) would often participate. He also said sometimes he would move up his visit by a day or two if there were “serious medical problems.”
Sending the sick ‘somewhere else’
In seminars and contract presentations to local sheriff’s offices and county councils, ACH officials emphasize that their personnel are “correctional trained” and that its practices have brought significant savings to most, if not all, of their clients.
In 2005, ACH CEO Doctor Norman Johnson went before Kentucky’s Daviess County Commission to pitch a new contract. He said “one of the first things” ACH does is “train the staff, not just the nurses but the correctional officers [on] how to not take any medical responsibility, because right now they are taking responsibility as they have to make a judgement call as to whether somebody goes to the doctor, et cetera.”
“You know from experience that something is so bad that somebody has got to go to the emergency room, and if they do, then it is covered under the contract,” Johnson added. He then went on to say the company avoids major costs by “identifying sick cases ahead of time” and having inmates with the worst medical emergencies released on their own recognizance or “sent somewhere else” so ACH and the county don’t have to be concerned about the cost.
Dr. Johnson explained the contract’s liability cap was rarely reached. He made it clear that exceeding the cap would not benefit any of them, saying they “cannot let [expenses] go over [liability limit], because if it does, [ACH is] not making money and [the county is] spending money and the only way we can keep this thing going is to keep [the county] very happy which [ACH has] been very good at.”
When pressed on how ACH is able to provide healthcare services at a lower cost than the county, Johnson responded, “The way it saves money is [ACH does] absolutely everything that is necessary for the care of the inmates. [ACH doesn’t] do absolutely everything the inmates want and when you start operating that way, the costs come way, way down.”
“[ACH is] very cognizant of inmate lawsuits and the eighth amendment rights of inmates,” Johnson also stated. “So [we] are very specific about how [we] do this.”
Dr. Davis’ license to practice medicine
On September 7, 1994, the Medical Board of California voted to suspend Dr. Davis’ medical license and he was placed on probation. Dr. Davis’ was apparently without legal counsel at the time he pled to his charges, and did not fully understand what his plea of nolo contendere meant. He was given a number of terms he was ordered to fulfill before his status could be restored, including additional exams and medical ethics training.
Ever since then, Davis has struggled to comply with California’s order and amend his status, and has said he’ll never go back to the golden state to practice medicine ever again. The Medical Licensing Board of Indiana learned of his suspension in California in 1996, and voted to suspend Dr. Davis’ license indefinitely after he failed to appear for a hearing on January 23, 1997. (Dr. Davis argues the notices were not sent to the proper address and failed to reach him overseas, where he was working on a medical mission in Indonesia).
Dr. Davis attempted to fight the ruling. In December 1998, Davis asked Medical Licensing Board of Indiana to rescind their decision, but they declined. The board denied his petition to modify his probation one week later. On September 10, 2001, the Virginia Department of Health Professions suspended Dr. Davis’ license to practice in that state after receiving word of his status in California.
Advanced Correctional Healthcare hired Dr. Davis in 2002, and the company wrote numerous glowing letters of recommendation to the board on his behalf over the next several years. In his own letters to the board, Davis detailed numerous financial and emotional hardships that created obstacles to his compliance with California’s orders: his wife had been in a serious car accident and the family now faced massive medical bills. He was paying to put his daughter through college, and she also had costly health care needs. He was the full-time caretaker of his elderly and dementia-stricken father as well.
Dr. Davis continued fighting his status and the Board kept ruling against him. In 2010, Dr. Davis was as close as he’s ever been to having his status amended. The Board moved to withdraw his probation in September of that year, but questions among Board members concerning unresolved issues with his case led them to ultimately table the decision at the last minute, at least until he completed all of his exams.
Davis’ last appearance before the Medical Licensing Board of Indiana was for a probationary appearance on June 25, 2015. Minutes are not taken for these meetings, but his medical license is still on probation.
‘Gaming the system’
Two years after former inmate Timothy Strayer filed a federal civil rights lawsuit over his medical care at the hands of Advanced Correctional Healthcare, Indiana laws had changed and jails were required to have licensed medical professionals conduct inmate exams. At the Dearborn County Detention Center in Lawrenceburg, the triaging of inmate medical needs was conducted by an unlicensed medical assistant named Kelly Hogg.
On August 28, 2014, ACH CEO Dr. Norman Johnson went before the Dearborn County Council to propose a $400,000 increase to their contract. Dr. Johnson told the council he had never seen a jail as large as the one in Dearborn County go so long without a nurse. He was pursuing the increase to hire a licensed nurse, as well as increase doctor hours and purchase more supplies and medications.
The jail had a part-time registered nurse by 2014, but Hogg was still arguably the de facto primary caregiver. Inmates made their medical complaints to Hogg, and while she was technically an employee of Dearborn County, she spent more hours than the doctor (who only came to the jail for a few hours once a week) or the part-time nurse seeing inmates and providing care.
Although ACH had recommended keeping Hogg at her job nine years earlier when the company proposed a contract for Dearborn County, the Strayer lawsuit and amendments to Indiana’s Administrative Code created some urgency to bring a licensed professional on site. Without mentioning the Strayer’s lawsuit by name, Johnson seemed to raise it several times during the August 2014 meeting, as he blamed an “untrained person” for getting “in the middle of medical care.” (“Strayer v. Dearborn County” is the only active federal lawsuit facing the jail, and was the only suit at the time of the meeting).
Johnson urged the council to hire more staff to guard against attempts by inmates to “game the system” and “get a trip to the hospital.”
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