danielle
02-02-2003, 09:57 AM
By ERIC NEWHOUSE
Tribune Projects Editor
--------------------------------------------------------------------------------
Officials argue state's prisoners get sufficient care regardless of cost
For two years, Montana denied medical treatment to Patrick Buckman Jr., a prisoner with a potentially fatal brain disorder, a national prison watchdog group claims.
"The state knew he had a life-threatening injury and did nothing to treat it," said Eric Balaban, staff attorney for the National Prison Project in Washington, D.C.
"They stalled and delayed until they could simply slow-roll him out the door and evade their responsibility," said Balaban.
Balaban says the case illustrates problems with medical care in Montana prisons. Prison officials, however, say the state must prioritize the medical needs of inmates and determine care on a case-by-case basis.
"I concluded that this was not in the range of serious and imminent medical problems that we could pay for," said Dr. Liz Rantz, the Department of Corrections chief medical officer of the Buckman case.
The issue may become even more contentious as Montana deals with budget deficits. Medical spending for prison inmates already is declining.
Despite medical inflation of about 10 percent a year, Montana spends 20 percent less per prisoner than it did seven years ago.
"Montana has a lot to do in providing health care that is reliable, timely, self-monitoring and self-correcting," Balaban said, adding: "I only get involved in the systems that are broken."
Balaban monitors Montana's prison system and eight others for the National Prison Project, a group which was founded in 1972 by the American Civil Liberties Union and uses class action litigation and public education to defend prisoners' rights -- especially in the areas of medical care and overcrowding.
Now Buckman, a member of the Gros Ventre Tribe who has a history of mental illness and drug and alcohol abuse, is back on the Fort Belknap Indian Reservation with few prospects.
"The chances are good I'll be dead before I get help," he told his sister recently.
Short circuit
Doctors diagnosed Buckman as having an arteriovenous fistula, or malformation, in his brain.
Called an AVM, it's a short circuit, in which blood pumps out of an artery and directly back into a vein without irrigating surrounding brain tissues with oxygen and nutrients.
"Fistulas can cause seizures and, in depriving the surrounding brain from blood flow, all forms of neurological deficit," said Dr. Richard M. Hirshberg, who has reviewed Buckman's case for the National Prison Project.
"They can bleed and cause death," added Hirshberg, a consulting neurosurgeon recently retired from Baylor University in Houston.
There's a 3 to 5 percent chance that a fistula will begin to bleed or that it will worsen, he said.
Doctors in Billings discovered the fistula a few months before District Judge Susan Watters sent Buckman to the state mental hospital in Warm Springs for treatment of bipolar disorder and schizophrenia.
Buckman was examined by Missoula neurologist Dr. Howard Chandler Jr., who recommended surgery on Sept. 26, 2000.
Three days later, however, Buckman was transferred from Warm Springs to the Montana State Prison to serve a sentence for assault.
To treat or not
Lawyers for the National Prison Project say those delays may have been unconstitutional.
They cite a 1976 Supreme Court decision which says: "Deliberate indifference to serious medical needs of prisoners constitutes the 'unnecessary and wanton infliction of pain' proscribed by the Eighth Amendment" to the U.S. Constitution.
In 1992 the court ordered that financial constraints cannot be used to justify a lack of medical treatment.
But prison officials say Montana's inmates are treated regardless of expense.
Buckman's medical record didn't justify complicated surgery, said Diana Leibinger-Koch, chief of legal services for the Department of Corrections.
"It's debatable whether he was having any seizures, and there was no correlation medically that they were caused by the AVM," she said.
Furthermore, she added, the risk of paralysis resulting from surgery was unacceptably high.
Pressing emergencies
"When the state receives prisoners with medical needs," Balaban countered, "it is obligated to provide treatment."
But Leibinger-Koch said the state is only obligated to treat pressing medical emergencies.
"The Eighth Amendment says we cannot be indifferent to medical problems," she said. "But you can't equate what is in a prisoner's long-term best interest with pressing medical needs."
The prison makes such judgment calls all the time, she said.
"If something is causing a problem right now, we have to take care of it," she said. "And we do."
She noted the case of one inmate with a sudden and severe medical problem who was flown to Seattle on a medical helicopter for surgery that cost more than $100,000.
She said cost was not a factor in Buckman's diagnosis. The original surgery was estimated to cost $50,000, but newer techniques could reduce that estimate.
Medical spending
State records show medical care for inmates fairly steady at about $7 million a year, although the state did save several million dollars in fiscal 2000 when it returned prisoners from Tennessee and Texas.
However, the number of inmates increased 34 percent in the past seven years.
In fiscal 1996, the state spent an average $1,016 per prisoner on medical care. In 2002, by contrast, that figure dropped to $799.
Corrections also uses any other funding source it can find, said Julianne Reardon, director of managed care for the department.
"Last year, we were able to use about $760,000 in Medicaid funds for our prisoners," Reardon said.
"We do fix the serious things that are causing serious problems," Leibinger-Koch said.
However, the state is not required to provide state-of-the-art treatment to inmates, she said.
"If a heart transplant would save an inmate's life, we would say we can't do that," Leibinger-Koch said. "But we would authorize heart surgery, and we do it all the time."
The prison has no AIDS cases, Deputy Warden Cathy Redfern said, but there are about 10 prisoners diagnosed with HIV.
"We provide drugs needed by inmates with HIV, but we don't give them the deluxe medical care or the latest drug cocktails provided to people on the outside," Leibinger-Koch said.
Determining treatment
All prisoners receive a checkup when they enter the prison, Redfern said. Thereafter, they receive care when they complain of problems, she said.
A prison doctor determines treatment. Afterward, a medical team consisting of the doctor, the medical chief of staff and an outside physician reviews the diagnoses.
"We very carefully review high-dollar things like CAT scans," Reardon said.
Rantz said 10 or 15 inmates might have cancer at any given time.
"Generally speaking, we treat it," she said. "We agonize over it a bit, but if they really need it, we'll treat it."
About 350 of the prison's 1,325 inmates are on a chronic care list for problems such as diabetes, asthma, hypertension or seizures. They're checked every three months, Redfern said.
About 30 percent of the prisoners suffer from hepatitis, said Rantz, adding that the department practices preventive medicine by providing inoculations and education about the virus.
Inmate complaints
"They say they do all these things, but I'm corresponding with 500 inmates scattered all over the state, and I know they don't," said Casey Rudd, a former inmate and founder of the Montana Criminal Justice Reform Coalition.
Her husband, Eddie Rudd, entered the prison system in 1996 for a felony DUI conviction with symptoms of hepatitis C, but never was told he had it until he was released a year ago.
"I think they knew it, because they took my blood when I entered prison," he said.
Eddie Rudd said a growth was cut off his hand after more than a year of constant requests. He added that prisoners face a long wait for dental work.
"They hold you off as long as they can until the pain is so bad you can't bear it no more and they finally have to do something about it," he said.
Casey Rudd said many inmates need treatment for mental illness, but few receive it.
Debbie Watson of Billings, mother of an inmate diagnosed with an alcohol-related neurodevelopment disorder, said her son has received little help for his brain damage.
"With no treatment, isolation and no meds, it is exacerbating his mental condition and he is getting a lot worse," she said.
"If he doesn't get help soon, he is going to wind up dead or with a total mental breakdown."
Problems with system
Balaban said Montana's correctional health care system underwent "seismic changes" over the past year.
"It lost its medical director, who had not been providing care for the previous several months, and there has been an entire turnover in the nursing staff over the past 18 months," he said.
At the same time, prison officials are under pressure to save money.
Two years ago, a legislative audit concluded the state spends an inordinate amount on medical care for prison inmates.
"The department spent an average of $3,813 per inmate for adult inmates housed in state-operated facilities during fiscal year 1998," the audit said. "This compares with other states which report an annual average of $2,544 per adult inmate.
Corrections officials say medical costs are high because the state has to maintain duplicative infirmaries in all its regional prisons.
Home without help
With only a 3 to 5 percent chance of bleeding, Buckman's AVM was not considered a pressing medical need.
The prison discharged him Aug. 15, ending its responsibility for his welfare.
"He was given $100 and some extra anti-seizure medication," said Amy Fettig, another attorney for the National Prison Project.
Now Buckman lives in a small duplex on the Fort Belknap Indian Reservation with his sister's family.
He is indigent and was rejected for Social Security Disability benefits. He's not eligible for full Indian Health Service benefits, he said, because he hasn't lived on a reservation recently.
Buckman was hospitalized twice recently with seizures.
"This fistula can be potentially quite difficult to treat," concluded Dr. Hirshberg, who organized a team at Baylor University to examine the brain scans.
The neurosurgeons determined the best treatment would be injecting the fistula with cyanoacrylic "glue."
But that technology isn't available on the Fort Belknap Indian Reservation, Balaban noted.
If Buckman's fistula begins bleeding or he suffers a stroke, he could be treated -- although at considerable expense.
"If he survives, taxpayers will be forced to face the consequences of not affording him preventive surgery beforehand," Balaban said.
"Or he may not survive."
Tribune Projects Editor
--------------------------------------------------------------------------------
Officials argue state's prisoners get sufficient care regardless of cost
For two years, Montana denied medical treatment to Patrick Buckman Jr., a prisoner with a potentially fatal brain disorder, a national prison watchdog group claims.
"The state knew he had a life-threatening injury and did nothing to treat it," said Eric Balaban, staff attorney for the National Prison Project in Washington, D.C.
"They stalled and delayed until they could simply slow-roll him out the door and evade their responsibility," said Balaban.
Balaban says the case illustrates problems with medical care in Montana prisons. Prison officials, however, say the state must prioritize the medical needs of inmates and determine care on a case-by-case basis.
"I concluded that this was not in the range of serious and imminent medical problems that we could pay for," said Dr. Liz Rantz, the Department of Corrections chief medical officer of the Buckman case.
The issue may become even more contentious as Montana deals with budget deficits. Medical spending for prison inmates already is declining.
Despite medical inflation of about 10 percent a year, Montana spends 20 percent less per prisoner than it did seven years ago.
"Montana has a lot to do in providing health care that is reliable, timely, self-monitoring and self-correcting," Balaban said, adding: "I only get involved in the systems that are broken."
Balaban monitors Montana's prison system and eight others for the National Prison Project, a group which was founded in 1972 by the American Civil Liberties Union and uses class action litigation and public education to defend prisoners' rights -- especially in the areas of medical care and overcrowding.
Now Buckman, a member of the Gros Ventre Tribe who has a history of mental illness and drug and alcohol abuse, is back on the Fort Belknap Indian Reservation with few prospects.
"The chances are good I'll be dead before I get help," he told his sister recently.
Short circuit
Doctors diagnosed Buckman as having an arteriovenous fistula, or malformation, in his brain.
Called an AVM, it's a short circuit, in which blood pumps out of an artery and directly back into a vein without irrigating surrounding brain tissues with oxygen and nutrients.
"Fistulas can cause seizures and, in depriving the surrounding brain from blood flow, all forms of neurological deficit," said Dr. Richard M. Hirshberg, who has reviewed Buckman's case for the National Prison Project.
"They can bleed and cause death," added Hirshberg, a consulting neurosurgeon recently retired from Baylor University in Houston.
There's a 3 to 5 percent chance that a fistula will begin to bleed or that it will worsen, he said.
Doctors in Billings discovered the fistula a few months before District Judge Susan Watters sent Buckman to the state mental hospital in Warm Springs for treatment of bipolar disorder and schizophrenia.
Buckman was examined by Missoula neurologist Dr. Howard Chandler Jr., who recommended surgery on Sept. 26, 2000.
Three days later, however, Buckman was transferred from Warm Springs to the Montana State Prison to serve a sentence for assault.
To treat or not
Lawyers for the National Prison Project say those delays may have been unconstitutional.
They cite a 1976 Supreme Court decision which says: "Deliberate indifference to serious medical needs of prisoners constitutes the 'unnecessary and wanton infliction of pain' proscribed by the Eighth Amendment" to the U.S. Constitution.
In 1992 the court ordered that financial constraints cannot be used to justify a lack of medical treatment.
But prison officials say Montana's inmates are treated regardless of expense.
Buckman's medical record didn't justify complicated surgery, said Diana Leibinger-Koch, chief of legal services for the Department of Corrections.
"It's debatable whether he was having any seizures, and there was no correlation medically that they were caused by the AVM," she said.
Furthermore, she added, the risk of paralysis resulting from surgery was unacceptably high.
Pressing emergencies
"When the state receives prisoners with medical needs," Balaban countered, "it is obligated to provide treatment."
But Leibinger-Koch said the state is only obligated to treat pressing medical emergencies.
"The Eighth Amendment says we cannot be indifferent to medical problems," she said. "But you can't equate what is in a prisoner's long-term best interest with pressing medical needs."
The prison makes such judgment calls all the time, she said.
"If something is causing a problem right now, we have to take care of it," she said. "And we do."
She noted the case of one inmate with a sudden and severe medical problem who was flown to Seattle on a medical helicopter for surgery that cost more than $100,000.
She said cost was not a factor in Buckman's diagnosis. The original surgery was estimated to cost $50,000, but newer techniques could reduce that estimate.
Medical spending
State records show medical care for inmates fairly steady at about $7 million a year, although the state did save several million dollars in fiscal 2000 when it returned prisoners from Tennessee and Texas.
However, the number of inmates increased 34 percent in the past seven years.
In fiscal 1996, the state spent an average $1,016 per prisoner on medical care. In 2002, by contrast, that figure dropped to $799.
Corrections also uses any other funding source it can find, said Julianne Reardon, director of managed care for the department.
"Last year, we were able to use about $760,000 in Medicaid funds for our prisoners," Reardon said.
"We do fix the serious things that are causing serious problems," Leibinger-Koch said.
However, the state is not required to provide state-of-the-art treatment to inmates, she said.
"If a heart transplant would save an inmate's life, we would say we can't do that," Leibinger-Koch said. "But we would authorize heart surgery, and we do it all the time."
The prison has no AIDS cases, Deputy Warden Cathy Redfern said, but there are about 10 prisoners diagnosed with HIV.
"We provide drugs needed by inmates with HIV, but we don't give them the deluxe medical care or the latest drug cocktails provided to people on the outside," Leibinger-Koch said.
Determining treatment
All prisoners receive a checkup when they enter the prison, Redfern said. Thereafter, they receive care when they complain of problems, she said.
A prison doctor determines treatment. Afterward, a medical team consisting of the doctor, the medical chief of staff and an outside physician reviews the diagnoses.
"We very carefully review high-dollar things like CAT scans," Reardon said.
Rantz said 10 or 15 inmates might have cancer at any given time.
"Generally speaking, we treat it," she said. "We agonize over it a bit, but if they really need it, we'll treat it."
About 350 of the prison's 1,325 inmates are on a chronic care list for problems such as diabetes, asthma, hypertension or seizures. They're checked every three months, Redfern said.
About 30 percent of the prisoners suffer from hepatitis, said Rantz, adding that the department practices preventive medicine by providing inoculations and education about the virus.
Inmate complaints
"They say they do all these things, but I'm corresponding with 500 inmates scattered all over the state, and I know they don't," said Casey Rudd, a former inmate and founder of the Montana Criminal Justice Reform Coalition.
Her husband, Eddie Rudd, entered the prison system in 1996 for a felony DUI conviction with symptoms of hepatitis C, but never was told he had it until he was released a year ago.
"I think they knew it, because they took my blood when I entered prison," he said.
Eddie Rudd said a growth was cut off his hand after more than a year of constant requests. He added that prisoners face a long wait for dental work.
"They hold you off as long as they can until the pain is so bad you can't bear it no more and they finally have to do something about it," he said.
Casey Rudd said many inmates need treatment for mental illness, but few receive it.
Debbie Watson of Billings, mother of an inmate diagnosed with an alcohol-related neurodevelopment disorder, said her son has received little help for his brain damage.
"With no treatment, isolation and no meds, it is exacerbating his mental condition and he is getting a lot worse," she said.
"If he doesn't get help soon, he is going to wind up dead or with a total mental breakdown."
Problems with system
Balaban said Montana's correctional health care system underwent "seismic changes" over the past year.
"It lost its medical director, who had not been providing care for the previous several months, and there has been an entire turnover in the nursing staff over the past 18 months," he said.
At the same time, prison officials are under pressure to save money.
Two years ago, a legislative audit concluded the state spends an inordinate amount on medical care for prison inmates.
"The department spent an average of $3,813 per inmate for adult inmates housed in state-operated facilities during fiscal year 1998," the audit said. "This compares with other states which report an annual average of $2,544 per adult inmate.
Corrections officials say medical costs are high because the state has to maintain duplicative infirmaries in all its regional prisons.
Home without help
With only a 3 to 5 percent chance of bleeding, Buckman's AVM was not considered a pressing medical need.
The prison discharged him Aug. 15, ending its responsibility for his welfare.
"He was given $100 and some extra anti-seizure medication," said Amy Fettig, another attorney for the National Prison Project.
Now Buckman lives in a small duplex on the Fort Belknap Indian Reservation with his sister's family.
He is indigent and was rejected for Social Security Disability benefits. He's not eligible for full Indian Health Service benefits, he said, because he hasn't lived on a reservation recently.
Buckman was hospitalized twice recently with seizures.
"This fistula can be potentially quite difficult to treat," concluded Dr. Hirshberg, who organized a team at Baylor University to examine the brain scans.
The neurosurgeons determined the best treatment would be injecting the fistula with cyanoacrylic "glue."
But that technology isn't available on the Fort Belknap Indian Reservation, Balaban noted.
If Buckman's fistula begins bleeding or he suffers a stroke, he could be treated -- although at considerable expense.
"If he survives, taxpayers will be forced to face the consequences of not affording him preventive surgery beforehand," Balaban said.
"Or he may not survive."