Advanced Correctional Healthcare’s Brutal Brand Of Jailhouse Medicine

Editor’s Note This is part one of Gaming the System, Brian Sonenstein’s three-part series on the privatization of correctional healthcare, and the consequences for prisoners when cutting costs is more important than patient health. -KO Part 1 Part 2 Part 3

Timothy Strayer was approaching 70 years of age and suffering from multiple chronic illnesses in the summer of 2011 when he was arrested for marijuana possession with the intent to sell. One year later, his family launched a federal civil rights lawsuit that is still in progress to this day, alleging the sheriff, guards and the private healthcare company contracted to provide medical care at the jail, Advanced Correctional Healthcare (ACH), failed to provide for his obvious and critical medical needs, allowing his health to deteriorate to the point that he would need to be hospitalized for nearly 200 days.

Shadowproof conducted a three month investigation of ACH and the Strayer family’s story. Through multiple interviews, analysis of several active federal civil rights lawsuits, hundreds of pages of medical board records, corporate documents and county meeting minutes, we uncovered shockingly similar allegations of abuse and misconduct involving ACH and the doctors who were responsible for Strayer’s care, as well as a valuable glimpse into the mindset of a little-known but highly-profitable industry thriving in jails and prisons across the nation.

Strayer had Chronic Obstructive Pulmonary Disease, heart disease, one kidney, chronic psoriasis and acid reflux prior to his incarceration. Nonetheless, under the supervision of his personal physicians and with access to his prescription medications, Strayer was living relatively comfortably.

According to the lawsuit Strayer v. Dearborn County, that all changed in July 2011, when Strayer was first held at the Kenton County Detention Center in Covington, Kentucky. He alleges he was not given his heart medication for 10 days — right up until his last day at that jail. (Kenton County’s health care is provided by another private inmate health care firm, Southern Health Partners).

Strayer was then transferred to Dearborn County Detention Center in Lawrenceburg, Indiana. The jail was severely overcrowded at that time, and Strayer was allegedly placed in the “drunk tank” for lack of cell space. He shared the communal cell and its only toilet with multiple inmates for a few days until he was moved to a two-bunk cell that already had two inmates living in it. He was made to sleep on a mat on the floor.

Already in a weakened state from his mistreatment in Kentucky, Strayer began to file medical requests. His psoriasis was getting worse and his skin began to flake off. Even though his wife, Kelley Kingston-Strayer, and his brother, Mike Strayer, had both given the jails a complete list of his prescriptions and contact information for his doctors, he was without stable access to his medication throughout his time behind bars.

Kelley was living in Kentucky at the time. She said her husband would call Mike and her frequently — sometimes more than once a day. He would often complain about the medical care at the jail and his inability to get access to his medications when he did. As time passed, Kelley noticed his voice sounded weak when they spoke on the phone.

At first, Kelley said her reaction was to tell her husband to advocate for himself. She told him to get the guards’ attention and let them know he was sick and needed to see a doctor. “Never in my wildest dreams did it occur to me that law enforcement would not take care of a sick inmate,” Kelley recalled to me in an interview this past spring. “It never ever crossed my mind.”

But less than one month after he set foot in Dearborn County Detention Center, Tim Strayer would be rushed to the hospital for emergency surgery to repair a perforated duodenal ulcer, which, as a CT scan of his abdomen and pelvis would later show, had caused “voluminous amounts” of free air and fluid to flood his abdominal cavity. Some doctors believe the perforation had occurred as many as four days before he was brought to the emergency room for treatment.

Despite the fact that Strayer’s health and medical care were supposed to be under the care and supervision of Dearborn County and Advanced Correctional Healthcare, the family would ultimately find themselves facing down a massive medical bill and a long road to recovery.

Inside Advanced Correctional Healthcare

Advanced Correctional Healthcare was founded in 2002 by Dr. Norman Johnson. Based in Peoria, Illinois, ACH is a rising star within a multi-billion dollar-per-year, taxpayer-funded industry, contracting with local jails to provide inmate medical services. In 2012, ACH made $37.6 million.

Today, ACH is one of the largest inmate medical providers in the state of Indiana, and its reach extends across the midwestern United States. The company oversees health care at over 200 jails across 17 states and advertises an expertise in providing treatment in the “correctional environment.”

Central to ACH’s business model is the belief that what might be considered proper healthcare on the ‘outside’ should in some instances be deemed inappropriate on the ‘inside.’ Documents produced by the company for the Itasca County Sheriff’s office in Grand Rapids, Michigan, for example, made clear “it is not the responsibility of the jail to supply care for general comfort illnesses such as mild acne, dandruff or dry skin.”

“As a result,” ACH writes, “the key to any utilization program comes down to the decision to treat or not to treat a given complaint.”

Someone was “crushing his chest”

On July 22, 2011, Timothy Strayer was mentioned in a preliminary report at the Dearborn County Detention Center. The officer writing the report noted Strayer said he felt like someone was “crushing his chest,” and thought he might have acid reflux.

After asking Strayer some questions about his symptoms, Officer Zachary Perkins spoke with the unlicensed medical assistant at the jail, Kelly Hogg. He was given Zantac and instructed to notify staff if he did not feel better by the morning.

Although she was technically only an administrative assistant and had no license or formal medical training, Kelly Hogg could be considered the de-facto primary caregiver at the Dearborn County Detention Center. Without a full-time doctor or licensed medical professional on site, inmates brought their medical needs to Hogg. If Hogg could not manage the issue on her own, she would call ACH site physician Doctor Nadir Al-Shami.

One night, according to the lawsuit, a guard thought Strayer looked ill and decided to take him to the clinic. Assistant Kelly Hogg allegedly did not know what to do when she saw him. Strayer told her he could not breathe and requested an oxygen tank, but the jail was not equipped with one. He became delirious and was vomiting bile, unable to keep anything down but small sips of 7-Up.

Days passed, and Strayer’s health continued to worsen. The family says other inmates became concerned and asked staff to help him. He begged to be brought to the hospital but was refused. He stopped calling home.

On August 1, Strayer filed a grievance with the jail, writing, “Medical treatment not anywhere near adequate. Doctor visit last two Mondays, no improvement, nor will there be.”

“My problems are so severe that a hospital stay is necessary,” Strayer wrote in an urgent and messy script. “Extreme psoriasis that no cream or ointment or [illegible] will help! In fact, [illegible]. Ear infection, blockage, skin rash, nothing has been done. Loss of hearing — problems! Hernia needs removal.”

“Have [social security] and will pay.”

ACH exempts “rare” diseases from prison treatment

Representatives from Advanced Correctional Healthcare claimed they would save taxpayers about $120,000 annually during their pitch to the Dearborn County Commission on February 15, 2005. ACH was the only offer on the table that day, on personal recommendation from a nearby sheriff — a friend of the commission who claimed the company saved his county $60,000.

ACH Director of Marketing and Sales Diane Anderson explained how the contracts typically work. The company would cover the first $10,000 of medical costs, and anything after would be the responsibility of the county.

Anderson said ACH would prefer to keep Dearborn County Detention Center’s assistant Kelly Hogg on staff because they felt she was doing a “good job.” She told the commission ACH would send its own physician to the jail once a week, with other doctors waiting on call 24/7 should there be emergencies or doctors who were unable to make their shifts. She claimed all of their staff were “correctional trained.”

ACH’s proposal covered all in-house medical services with some notable exceptions: “anything that deals with HIV/AIDS, hepatitis, rabies, [multiple sclerosis], cancer or court order[ed treatment].” All on-site pharmaceuticals and over-the-counter drugs would be included except for those dealing with these specific conditions. If they had to treat someone suffering from one of these exceptions, they would bill the sheriff at their “discounted network cost.”

In corporate documents, ACH states these illnesses and diseases are excluded because of their rarity among the prison population. However, the Centers for Disease Control (CDC) found “inmates in jails and prisons across the United States (US) are disproportionately affected by multiple health problems, including HIV, other sexually transmitted infections (STIs), tuberculosis (TB), and viral hepatitis.”

A different study by the Bureau of Justice Statistics also found inmates suffer from chronic health issues disproportionately, specifically that “14% of jail inmates reported ever having tuberculosis, hepatitis, or other STDs excluding HIV or AIDS, compared to 5% of the general population.”

Additionally, the contract would not cover “elective care,” which the company defined as medical treatment that, “if not provided would not, in the opinion of ACH’s Medical Director (a licensed physician employed by ACH), cause the inmate’s health to deteriorate or cause harm to the inmate’s well being.”

The meeting adjourned while members considered their only inmate health care proposal. By March 1, 2005, the contract had been approved.

When hernia surgery becomes ‘elective’

ACH Dr. Nadir Al-Shami did not report to the Dearborn County Detention Center for his rounds on August 2, 2011 — one day after Tim Strayer filed a medical request asking to be taken to the hospital. Dr. Ronald Davis was on back up duty that day and went in Dr. Al-Shami’s place.

Dr. Davis said in his deposition that Strayer was able to walk and talk but had obvious trouble moving. It was clear to him Strayer was very ill and was suffering from numerous, severe medical problems. The doctor recalled Strayer was an elderly man, and they spent 30 minutes together — the most time Dr. Davis spent with any inmate that day.

Dr. Davis also said in his deposition he learned Strayer had not been able to eat for over a week because he believed he had a hernia causing him immense pain. He observed Strayer’s many health issues. He found Strayer’s ear was extremely swollen and it was causing him a lot of pain and some hearing loss. Dr. Davis saw Strayer had a severe rash covering his body that was extremely itchy. He noted Strayer’s groin was very raw and looked like it might have a fungal infection.

In his deposition, Dr. Davis also mentioned he thought Strayer had a fairly large hernia in his groin. Davis also said he noticed Strayer had an umbilical (or ventral) hernia in his mid-abdomen, but didn’t write it down in his exam notes “because [Strayer] wasn’t complaining about it.”

In ten years, Dr. Davis said in his deposition, he saw fifty to one hundred inmates with hernias and only sent one or two for surgery, so he did not think Strayer’s apparent hernia was an emergency. Dr. Davis determined both hernias would need to be repaired by surgery, but would only send him if they had become strangulated. Otherwise, the surgery would be considered “elective” and would be outside the scope of care ACH considers appropriate for the “correctional environment.”

Assistant Hogg gave Strayer some medications and Dr. Davis ordered blood work. Strayer’s wife Kelley contends that blood work was never completed.

‘Control your pharmaceuticals’

On October 25, 2004, ACH’s Diane Anderson was before the Daviess County Commission in Kentucky, telling commissioners the best way to keep inmate medical costs down was to “control your pharmaceuticals.” She said the jail had “a lot of inappropriate high dollar pharmaceuticals in their facility according to national standards.”

She told the commission this was not meant as an insult to their doctor, and in fact, their doctor was probably an excellent community physician. “But the correctional environment is different,” Anderson said, then added:

When you get inside the correctional environment, you don’t need sleeping pills, you don’t want narcotics, and you don’t want a lot of psychotropic drugs unless they are medically indicated. [Anderson] stated they see not just in Daviess County, but they are in four states right now and historically, when they go in, there are a lot of inappropriate medications as the doctor is taking care of the wants. He is still treating inside the environment like he would the outside world, and there is nothing wrong with his treatment but within the correctional facility, you cannot have inappropriate medications.

One commissioner pushed back and reminded Anderson some inmates stay up all night and can’t sleep. “The jail has some guys who need to be calmed down in some way,” the commissioner stated. “If you start taking those medications away, you might cure one problem but create two more.”

Anderson disagreed. She claimed in their experience, ACH had been able to get by with “inmate health education information” they provided to sheriffs which instructs inmates on how to care for issues like insomnia on their own.

‘You’re fucking killing me’

Timothy Strayer’s wife Kelley and his brother Mike were growing concerned. They hadn’t heard from him for the last few days, which was unusual. Kelley knew he had been sick, but she was too far away to visit. She decided to ask Mike to visit because he lived in Cincinnati and could get to Dearborn County Detention Center more easily.

When they spoke, Mike mentioned he noticed his brother’s voice was barely above a whisper during their most recent phone conversations. He promised he would visit the jail and check up on him.

At around 6:10 AM on August 3, 2011, Strayer called for the doctor complaining of shortness of breath. Officer Perkins contacted Kelly Hogg, who instructed the officer to give Strayer an inhaler.

A jail log entry filed by Officer Perkins stated “[Strayer] refused his inhaler, looked at me and said, ‘I don’t need my inhaler. I need fucking oxygen.’ After I informed him that we do not have oxygen to give him, he proceeded to tell me, ‘You’re fucking killing me.'”

Assistant Hogg then told Officer Perkins to call Dr. Nadir Al-Shami, who instructed them to watch Strayer and call emergency services for oxygen if his condition worsened.

Four hours later, at around 10:00 AM, Strayer’s brother Mike entered the jail. In a letter he wrote to his lawyers after the visit, Mike said, “Within 5 minutes it was obvious that [Tim’s] life was in danger.”

“His physical condition was appalling,” Mike wrote. “He was very frail, emaciated and pale and he was in obvious pain. His entire arms were a deep purple color with scales covering the entire area. His breathing was labored and could not speak above a whisper. He told me he was dying.”

“His strength was such that he could not continue the visit,” Mike recalled. “It lasted less than 5 minutes.”

Mike went to the jail reception desk to look for help and told prison staff there of his brother’s condition. He urged them to send him to the hospital immediately, leaving two voicemails for Assistant Hogg who was unavailable at the time. He drove to the office of the prosecutor in his brother’s case, but was denied a meeting.

Mike went home and emailed and faxed everyone he could. “I do not believe that without your immediate attention he will survive,” he wrote to the Sheriff. “Certainly, one of you has the authority to see that he receives the care that he urgently needs without further delay or hesitation. This is a dire situation and needs the full attention of someone with the authority to see that he receives medical care without the need of a formal request or judicial order.”

Kelley said she could tell something was wrong when Mike called her back. He told her she needed to get on a plane to Indiana immediately: Tim was not well. He said he wasn’t sure what was happening, but it was bad. Kelley caught the next flight with the help of close friends.

As Mike sounded the alarm about Strayer’s health, Assistant Hogg had Strayer transported to Dearborn County Hospital.

Timothy Strayer goes into shock

An expert medical report compiled by Dr. Lynne E. Eiler stated that on August 3, Strayer had described his pain to medical staff at Dearborn County Hospital as a ten on a scale of one to ten. He hadn’t eaten since July 29 and had been vomiting regularly. He said his symptoms began about four to five days before coming to the ER — about one day after his last meal.

The report states Strayer was in shock. Dr. Eiler estimated his perforated ulcer may have gone as long as twelve to forty eight hours without medical attention, and possibly longer. He believed this was consistent with the timeline and Strayer’s claims of pain. He determined Strayer was “critically ill” and “beyond presentation of new onset of perforation.”

Dr. Eiler believed the two prison guards who had observed Strayer in his deteriorating state, as well as Dr. Davis, who saw Tim on August 2, demonstrated “deliberate indifference” by not immediately sending him to the hospital. “The system failed Tim,” he wrote.

When Kelley arrived at Dearborn County Hospital, her husband was already in the intensive care unit on a ventilator with a guard at his bedside. He had been ordered to surgery within 45 minutes of his arrival at the hospital, and what Dr. Davis had assumed was a hernia was in fact stomach fluid pooled in his groin from his perforated ulcer.

After ten days at Dearborn County Hospital, Strayer’s condition was still not improving. On August 11, doctors determined he would need additional surgery. Kelley said that afternoon, Sergeant Amy Vance entered the room with a trash bag and said he was being “ROR’ed,” or released on his own recognizance. The trash bag contained Strayer’s belongings.

Kelley said she told Sergeant Vance she didn’t understand what being “ROR’ed” meant. She claims Vance threw the bag at her feet and said, “it means this isn’t over.” Now that Strayer was released on his own recognizance, his family had effectively assumed responsibility from ACH and the county for the full cost of his medical care.

Strayer was soon rushed to the University of Cincinnati Hospital in Ohio for additional surgery. Immediately after his intake examination, Kelley said a surgical ICU nurse pulled her out of the room and angrily confronted her about her husband’s condition, unaware he had just come from a jail.

“The nurse said, ‘have you seen your husband’s bottom?’,” Kelley said. “I said ‘no’ and she said, ‘he has a stage four decubitus ulcer. He has a bedsore. Where did he come from? Did he come from a nursing home?’ They thought he was an abuse victim.”

“The nurse rolled Tim onto his side,” Kelley told me. “On his tailbone, there was a hole the size of baseball. The flesh was black and rotted and the infection had eaten through the muscle, tissue and tendons, and all the way down to the bone”

“That was it for me,” Kelley told me. “After that, I started calling civil rights lawyers.”

‘Deliberate indifference’ and devastating medical bills

Timothy Strayer spent at total of 196 days in five separate medical facilities across three states after less than one month as a patient of Advanced Correctional Healthcare at the Dearborn County Detention Center.

Eleven days were spent in Surgical ICU, thirty three days in Critical Care and twenty three days on a Step Down Floor. He moved between hospitals for months before finally being sent to a nursing home to rehabilitate. He was then sent back to Indiana to resume his twelve month prison sentence.

Strayer’s total medical bill came to $685,135.94 — nearly three times the amount Dearborn County paid Advanced Correctional Healthcare for the first year of their contract. Now that Strayer is on dialysis, that number is expected to grow.

In their lawsuit, the Strayer family contends the defendants’ “deliberate indifference to Tim’s medical needs” constituted a violation of his Fourth and Fourteenth Amendment rights. They argue “Tim has incurred very substantial medical bills and lost wages, loss of enjoyment of life, and continues to suffer risk of death as the result of the complications received as the result of the defendant’s’ negligence and deliberate indifference.”

Dr. Al-Shami was dismissed from the lawsuit because he did not actually see Tim the week he was taken to the emergency room. Dr. Davis was dismissed too, because Strayer was so delirious the day they met he cannot fully remember his exam; he has no memory of what he told Dr. Davis on August 2, and so the judge determined the case could not proceed against him.

Advanced Correctional Healthcare was named as a defendant in the initial complaint, but is no longer part of the suit — which is still ongoing against Dearborn County Sheriff and several officers at the jail.

Advanced Correctional Healthcare, Dr. Davis, the Dearborn county sheriff and his lawyer, and members of the county council did not respond to requests for comment by publication. Dr. Al-shami could not be reached.

Correction: An earlier version of this article stated Tim Strayer was convicted by jury when in fact he had not yet gone to trial. The author sincerely regrets the error.