House Call

‘House call’ could have a whole new meaning for inmates in custody of Milwaukee County

Milwaukee County Sheriff David A. Clark Jr. says inmates with health insurance or cash at the County Jail and House of Correction should be able to call their own doctors, dentists, chiropractors or other licensed professional under a pay-as-you-go reform.

“It’s something we have to look into because of the financial crisis,” Clark said in a 90-minute interview.

Not only is medical treatment for prisoners expensive to taxpayers it is in some cases not very good. The county is under the gun to improve service according to the terms of a consent decree arising from a class-action lawsuit against the state Department of Corrections and Milwaukee County, and Clark acknowledges his department is behind on the timetable.

Even without costly improvements required by the consent decree, the Sheriff’s Department has been a perennial bur under the county’s budgetary saddle for years and the Medical Unit has been a wild card. A MilwaukeePress.Net examination of interoffice communications from Controller Scott B. Manske to Board Chair Karen Ordinans shows Sheriff’s Department budget deficits of $3.6 million in 1998; $3.27 million in 1999, partially offset by a $870,000 contingency fund transfer; $4.125 million in 2000, offset in part by a $1.125 million cash infusion to cover prescription drug costs; and $4.7 million in 2001, offset partially by a $2.4 million fund transfer to cover unbudgeted medical costs, including $1 million for drugs.

The cost of transporting prisoners for outside treatment -- more than $300,000 last year -- also is a concern to politicians like County Supervisor T. Anthony Zielinski, who wants government to be efficient and effective.

Yet while Clark’s department has the mandate of providing health care in the jails, he says sworn officers should be focused on law enforcement, not medical care. He says allowing outside doctors to treat paying patients would allow an inmate the same level of care while in custody – providing the doctor is willing to jump through the yet-to-be codified hoops – without burdening taxpayers and leaving deputies to make medical decisions.

A recent MilwaukeePress.Net investigation of the health services at the jail and House of Correction suggests that intake procedures often fail to adequately identify some prisoner ailments, communication within the institutions is problematic and failure to identify insured inmates has cost taxpayers millions in lost reimbursements while in some cases denying them medicine they would otherwise have.

A recent case involving retired postal worker Phillip J. Werner illustrates many of those problems.

Werner died at the House of Correction from heart disease on Oct. 12, 2001. There's no question that, medically speaking, Werner was a walking can of worms even before he was arrested and booked into the Criminal Justice Facility Oct. 6 for misdemeanor disorderly conduct. Werner was transferred to the House of Correction Oct. 9, medical examiner records state, and he was suffering from hypertension, schizophrenia, a "hypercoagulated state and diverticulosis." He also was psychotic, his brother told medical authorities. The medical examiner's report says Werner was supposed to be taking serious medication, including Zyprexa, an antipsychotic drug; Depakote, prescribed for patients prone to seizures, panic attacks and obsessive-compulsive disorders; and Ambien for sleep.

A MilwaukeePress.Net source says that although a report sets the time 911 was called as 9:19 a.m., "[deputies] call over the radio to the nurses to say they have an emergency" before calling outside for help.

The source tells MilwaukeePress.Net that the nurses called back to ask what kind of emergency. It wasn't until the Sheriff's deputies arrived that any lifesaving procedures were started because "the nurses didn't know how to work the oxygen."

"He was there two or three days and they didn't give him any of his medications," the source says.

According to the consent decree -- reached after nearly five years of litigation --the state and county were to limit the jail population to 1,100 inmates and enhance the medical services at both the jail and House of Correction.

Mary Gundrum, the Legal Aid attorney who represents the class of plaintiffs in the case, tells MilwaukeePress.Net that the settlement agreement called for medical screening of all prisoners at the time of booking. Yet the Sheriff’s Department concedes that it has no records of insurance coverage – data the screening should have generated.

Gundrum said the government may have been motivated to agree to medical screening after local attorney and former UW Regent Paul Schilling, 51, died July 23, 1999, while in custody at the County Jail, where his diabetic seizures were mistaken for drunkenness.

Whatever benefits there may be to reform that allows outside doctors to treat patients like Werner and Schilling, some question what benefit there will be for the estimated 90 percent of inmates without insurance.

Clark, who inherited these problems in March when former Sheriff Lev Baldwin bailed out with a pension, acknowledges that prisoners without insurance or cash should not expect the same level or type of treatment at taxpayer expense as their insured cell mates. Uninsured or indigent prisoners are entitled only to “reasonable” treatment at taxpayer expense. Medical professionals employed by the county would determine what’s “reasonable,” Clark says.

Clark said that if a prisoner’s insurance provided chiropractic care, for example, the Sheriff’s Department should provide a place for a private chiropractor to treat a prisoner, and would charge the visiting practitioner for the use of county space.

But chiropractic treatment is not “reasonable” for uninsured prisoners, he says, and cites anecdotally that his own insurance cut him off from chiropractic care although he was covered for a period. Clark tells MilwaukeePress.Net there is no plan in place at this time to create new space for private care to be given, but discussed the possibility of outside providers using existing infirmary space when available.

Kit Murphy McNally, of the Benedict Center, points out that the Wisconsin Administrative Code for jails says the Sheriff must provide or secure "necessary medical treatment" for inmates in custody.

“Courts have held that necessary, appropriate, and reasonable health care provided to accused and adjudicated offenders in a local detention facility must reflect contemporary community standards of care,” says McNally, whose organization works with Legal Aid of Wisconsin in the class-action lawsuit.

“Health care administrators in the community and in the jail are the arbiters of those standards, not law enforcement or politicians. When the government takes custody of an individual, it assumes responsibility for that person's well being. Appropriate health care is integral to well-being, and strong legal and judicial mandates back this conviction.”

While most county government reform is motivated by the need to cut costs, there is no sign money saved on insured inmates would mean better care for the other 90 percent.

For example, after MilwaukeePress.Net reported that the county had neglected to seek reimbursement for treatment of inmates with insurance, Zielinski says officials are scouring the records to find who might have been covered, and those records may go back as far as seven years, a Sheriff’s Department spokesman says.

But even if the county gets reimbursed, the money would go into the general fund, not to the Medical Unit, and Clark thinks it should stay there.

If the money came from property taxes, Clark says, reimbursement rightly should go back to taxpayers, not to his department.

Meanwhile, Zielinski concedes he is less concerned that inmates get the best possible medical care than he is that the government run efficiently.

One scenario that might address both the cost and quality of health care in the jail and House of Correction would be to get the infirmaries certified so that the county can collect the reimbursements directly from Medicaid or private insurers.

But Clark said he did not want the medical treatment issue to be based on making money.

Joseph E. Cooper, accounting manager for county health services, tells MilwaukeePress.Net that with the jailhouse clinics as they are, “the county could not get money because it is not a medical provider.”

To be reimbursed, the county would have to identify who has insurance, then notify the provider who would then seek reimbursement from the insurance company or government program.

For example, if an inmate with insurance were transported to St. Luke’s Hospital, the hospital would bill the county and the county would process the bill and determine whether the patient was in jail and really treated. If the bill were legitimate, the county would order a check be issued for the treatment.

If later, it were discovered that the patient was insured, the county would tell St. Luke’s to bill the insurance company and then ask St. Luke’s for a refund of the money the county had paid.

“But if we were certified, we could bill directly for services provided in the jail or House of Correction,” Cooper said.

Certification would likely improve the quality of care for all prisoners, but it would also increase the cost to the county.

Clark said rather than wait for construction of new examining rooms for outside doctors to visit, inmates might conceivably be seen by their own physicians in existing infirmary facilities when they are available, but they would have to pay for the use of the room.

McNally says she doubts personal physicians will have any interest in making jail calls, with or without insurance reimbursements.

“And I can't imagine who would want to pay the jail for the inconvenience and frustration of accessing a patient there. I think it would probably be detrimental to the inmate trying to access his personal physician, as well. The security procedures required to meet his request, combined with his doctor's availability, would significantly delay his access to health care.

“A better solution is the one agreed to by the County and the Sheriff in the Consent Decree: Elevate the standards of care in the jail for every inmate and study all available, effective, and reasonable community alternatives to pretrial detainment so that health care costs and those detained awaiting trial will be kept to a minimum. The Benedict Center has long advocated for accreditation of medical and mental health services in the jail and House of Correction to ensure a nationally accepted baseline of care for every detainee and inmate. We believe this is in the best interest of every person held at the Jail and House of Correction, their families and loved ones, and the greater community.”

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House Death Probe Gets Deeper
By Geoff Davidian
Shepherd-Express

Nov. 8, 2001 -- Milwaukee County Sheriff Lev Baldwin has good reason to conduct a thorough investigation of the Oct. 12 death of Phillip J. Werner at the House of Correction.

An autopsy showed the postal worker died of heart failure resulting from heart disease.

Mary Gundrum of the Legal Aid Society, who represents the plaintiffs in a class-action lawsuit against the state Department of Corrections and Milwaukee County, tells Shepherd Express she has referred Werner's case to the court-appointed medical monitor to determine whether the House is living up to the terms of the settlement agreed upon last spring.

According to that agreement-reached after nearly five years of litigation-the state and county were to limit the jail population to 1,100 inmates and enhance the medical services at both the jail and House of Correction.

"I can absolutely say that any death at the House is a case of concern for this class," says Gundrum.

There's no question that, medically speaking, Werner was a walking can of worms even before he was arrested and booked into the Criminal Justice Facility Oct. 6 for misdemeanor disorderly conduct.

Werner was transferred to the House of Correction Oct. 9, medical examiner records state, and he was suffering from hypertension, schizophrenia, a "hypercoagulated state and diverticulosis." He also was psychotic, his brother told medical authorities.

Gundrum tells Shepherd Express that the settlement agreement called for medical screening of all prisoners at the time of booking. She said that if the screening had been done, Werner might have been a candidate for "4C," a special part of the House reserved for prisoners with mental or psychiatric problems, where he might have received care or treatment required by his condition.

But not necessarily, Gundrum says. "If the medication controlled his behavior, if he won't strike out at people or be victimized, he might be appropriately in the general jail population."

She said the government may have been motivated to agree to medical screening after local attorney and former UW Regent Paul Schilling, 51, died July 23, 1999, while in custody at the County Jail, where his diabetic seizures were mistaken for drunkenness.

The medical examiner's report says Werner was supposed to be taking serious medication, including Zyprexa, an antipsychotic drug; Depakote, prescribed for patients prone to seizures, panic attacks and obsessive-compulsive disorders; and Ambien for sleep. Records show he was given a tuberculosis test the morning he died.

Gundrum says Werner should have been screened before he got a tuberculous test. "Why didn't they catch this stuff at the front end?"

Also in question is what transpired between the time on Oct. 12 when other inmates told authorities that Werner was ill, and the time the 911 call was made.

One critic of what happened at the House Oct. 12 tells Shepherd Express that although a report sets the time 911 was called as 9:19 a.m., "they call over the radio to the nurses to say they have an emergency" before calling outside for help.

The source tells Shepherd Express that the nurses called back to ask what kind of emergency. It wasn't until the Sheriff's deputies arrived that any lifesaving procedures were started because "the nurses didn't know how to work the oxygen."

"He was there two or three days and they didn't give him any of his medications," the source says.

This is just what the agreement was meant to avoid. Estimates earlier this year suggest that the cost of providing medical care for Milwaukee County Jail inmates could rise $3 million annually, to about $9 million per year, under the settlement.

"If we see the screening was bad, the remedy for us would bring a motion for contempt," attorney Gundrum says.

"They have a specific set of questions," she says. "They're supposed to ask if the prisoner is on medications at the time of booking."

"If the personnel who operated the screen were negligent, that's a problem."

Sheriff's Department spokesperson Capt. Sherry Weber says the investigation will conclude next week.

"I'm worried, let me tell you that," Gundrum says, "because [Werner] was both medically and mentally compromised."

Eileen Weller, administrative manager at the medical examiner's office, says it is possible that Werner had all of those medical and mental problems yet still not display any symptoms.

"Sometimes, the first sign of heart disease is death," she says.

Medical employees at the House refused to answer questions about the case.