Stepping Up into Management

In my 9^th year at SCI, Correctional Medical Services took the contract back again.

              I’m not sure many people realize this, but the only population in the US that is required to have medical care is the inmate population.  Litigation has been the only way to change things in this system, and, as a result of litigation, the courts have decreed: when you put someone behind bars and take away their ability to access medical care, you must provide that medical care.  It must be medical care to the acceptable community standard.  The punishment of incarceration is taking someone away from home, family, friends; bad medical care is not supposed to be part of the punishment.

              Contracting prison medical care out to private companies is basically an attempt to protect the state from litigation.  If something goes wrong, the state didn’t do it, the contractor did.  The companies in the business (I’ve worked for six of them) try to provide good in-house general medical care, but do strict review and control of outside consults, hospitalizations, procedures, and medications that are not on formulary in an attempt to control costs.  After all, their profit is basically a bet; they make the contract and bet that they can bring it in cheaper and make a profit.  When a request for proposal goes out, the bidders come in and look at the facilities, but they are not permitted to talk to the employees of the current contractor.  Basically, they get the information the state wanted them to have and must make their bids based on incomplete information.  In Delaware, the lowest bid was never the current holder of the contract; they know it’s going to cost more.  So the contract changes every time.  I have worked on two contracts that ended precipitously; the contracting company “bugged out” when they couldn’t make ends meet on the terms of the contract.  In Delaware, I worked on five different contracts in 10 years, and for three different companies.  

              Whenever a contract changes over, medical care deteriorates for 6 months.  Patients waiting for procedures or consults have to have requests filled out for and approved by the new company.  A three month wait becomes a 6 month wait.  Some changeovers are relatively amicable, but others are hostile.  I went through one where the company leaving backed up trucks to each facility and stripped medical.  The next morning there wasn’t a Band-Aid or 4x4 or O2 tank or ECG machine left.  Nothing but the furniture!

              Most of the prisons I worked in used paper records.  The charts then belonged to the prison.  Electronic medical record systems are expensive, and if the contractor puts one in, what happens to the records when the contract changes? 

              Under most contracts (but not all), all the medical employees: doctors, nurses, aides, clerks, work for the contractor.  When a contract changes over, most will stay and work for the next contractor.  The facility medical directors stay, but the state medical director will usually move on with the previous employer.  It’s fine for physicians, who are well paid, but I’ve never understood why the nurses stood for it: at the contract change, the employees have a new employer.  They lose seniority, they frequently don’t get the hoped for next raise, they get bumped back to start on vacation days!  It’s not a good deal for them.   

              At my last contract change in Delaware, the company that had the contract “bugged out” (actually, they went “belly up”, bankrupt by the Delaware contract).  Correctional medical services, a company that had done the same thing the last time they had the contract, was offered the extra nine million that FMM had asked for to stay in the contract, and was asked to come in right away.  This after the legislature said they would never use CMS again, after they “bugged out” two years into a 6 year contract the last time they were in Delaware.

              When CMS took the contract, a number of our doctors left.  New ones that they hired said they would work in the prison but wouldn’t take night call.  Well, someone had to take the after-hours calls.  It ended up being me.  After two months I was taking the night call for the entire state: The 4 major facilities: Gander Hill in Wilmington, Delaware Correctional Center in Smyrna, the Baylor Women’s Prison in Wilmington, and Sussex Correctional in Georgetown.  I also took call for 6 small work-release facilities.  It was annoying to get so many calls at night, but the nurses tried very hard not to call, even waiting on orders for new intakes (sometimes when they shouldn’t have waited!).  And they were paying me extra for this.   

              Our new state medical director came down from the New Jersey contract, where he had been assistant medical director.  He would meet all the physicians monthly, one of the advantages of such a small state.  New intakes at Gander Hill were so backed up, he had us come up and do intake physicals assembly line style on Saturdays.  For which they paid well, but Gander Hill was 90 miles from my house, and I was a single parent with 2 kids, so I wouldn’t have chosen to do this. 

              Every month at our physician meeting, our medical director promised that, as soon as his Delaware license came through, he would take some of this on: start seeing patients at Gander Hill and start taking call himself.  After about 4 months of these promises, the administrative head of the contract started to wonder why it was taking so long for Dr. H.’s Delaware license to come through.  Turns out, he’d never applied for a Delaware license.  He had been lying to everyone ever since he took the job!  So, they fired him. 

              They fired him on Wednesday.  On Thursday, I called the Administrative head and said, “Look, I’m just about the only doctor you have left.  I’m the only one taking call.  I’ve been working in corrections for 9 years.  This is the third time I’ve worked for you.  I want to be medical director!”  He said he would call Dr. G, one of the directors of the company, but it sounded like a good idea to him.  He thought I should go to Dover the next day and talk to Dr. H. about the job while he was packing up to leave.

              So I went to Dover.  Dr. H said he knew, in the first couple of days, that the job was not for him, and he wanted to go back to Jersey.  So he just didn’t apply for the license.  He just figured when it all caught up with him, he would just go back to his position as assistant medical director of the New Jersey state contract.  What he hadn’t figured on was that it was all the same company.  He said, astounded, “They hollered at me!  They actually hollered at me!  No one has hollered at me since I became an adult!”  They also told him that he would never work for CMS again anywhere.

              While we were having this discussion, he got a phone call from his daughter, who was going to LaSalle College in Philadelphia.  She complained about a basketball player who wanted her to go out and was having trouble taking “no” for an answer.  When he hung up from her, he called someone he knew from his time in a prison in New Jersey, who was now working as a security guard at LaSalle.  He explained the problem his daughter was having, and his concern, especially since some other basketball players had recently been tried for rape.  The man apparently asked if he wanted the boy roughed up, but Dr. H. said no, just to put some pressure on him so he would stay away from his daughter.  I was totally blown away.  I had never actually known anyone to take that kind advantage of an inmate contact! (Although I do remember a resident at Temple getting a refrigerator and 4 tires from a pimp he'd been taking care of, but he wasn't an inmate, just a criminal!)

              I got the call later that day from Dr. G.  He thought it was a great idea.  I could start right away.  I knew the mechanics of the job from my side, and Dr. H had gone over them: reviewing requests for outside consults and non-formulary medication, thereby controlling costs, was considered the most important part of the job.  Dr. G said he would come down from St. Louis to teach me the computer system.  I could start as soon as they found a replacement for me at SCI.

              Between Friday and Monday, the job changed.  Dr. H’s job was full time, even though Delaware only had 4 major facilities and fewer than 6000 inmates.  But Monday, Dr. G told me the state medical directorship would only be a part-time job.  I would spend 20 hours a week as medical director, at one hourly rate of pay, and 20 hours a week as a staff physician at a lower rate of pay, filling in where needed!  I took the position anyway.  (I don’t think the job would have changed if I had been a man; yet, perhaps a man would have said “No way!” to the new job terms.  There might be a reason for that glass ceiling!)  Mistake!  It meant driving to Wilmington several days a week trying to make sure the inmates at Gander Hill got medical care.  I was spending hours on the road.  Dr. G. did come down to teach me the computer system, but then exempted me from “all the reports that Dr. H had to do” (for which he got paid at the medical director rate and didn’t have to drive all over the state), so I could fill in as needed at the other prisons (which Dr. H couldn’t do, since he didn’t have a Delaware license, and for which I got paid less!).

              It only took a couple weeks to find a replacement for me at SCI.  Like Dr. H., it didn’t take very long for me to realize I wasn’t staying very long in this job.  I started in November.  In January I got a call from Dr. K, who had been medical director of one companies I had worked for in the past.  Her company had landed the Tennessee contract; would I be interested in coming to interview as state medical director?  YES!

              So I flew to Tennessee in January.  I was most impressed by the greenness.  Delaware had been having droughts in the summer for 6 years, so by fall everything was brown and dry until the winter wheat started to grow.  In January, in Tennessee, even many of the lawns were still green!  I spoke with Dr. K but they hadn’t cleared my coming with TDOC (the Tennessee Department of Correction).  Many of the people who would need to interview me from TDOC were out of town, so they would arrange a video interview after I went back to Delaware.

              The video interview had me standing at a podium in front of a camera in Delaware and 8 people from TDOC sitting in Nashville.  They asked how I would cope with 17 major institutions, 19,000 inmates and almost 40 providers: ½ physicians, and ½ nurse practitioners and physicians assistants?  Beats me!  They asked what my management style was.  What’s a management style?  In Delaware, I never had time to figure out a management style; I was too busy seeing patients.  I had gone to med school, not business school; I had an MD, not an MBA.  This was all new to me!

              But TDOC accepted me, somewhat to my surprise after that interview.  I discussed it with the kids: Diane was graduating high school in June and Nerissa would be starting high school in September, so it seemed a good time to make a major move if I was going to.  The kids said “Go for it, Mom”.  I told the company that I couldn’t move until June; Diane needed to finish high school where she was.  They didn’t like it, but their interim medical director agreed to stay until then.  Nerissa and I flew down again to find a house.  Did it the way I like: looked at 9 houses and bought one!

              I got out of that job in Delaware just in time.  Gander Hill in Wilmington (the names of the prisons have all been changed since then) was the biggest intake facility, so it had the largest number of inmates going through alcohol and drug withdrawal.  They had a pretty big infirmary, but only had two hospital beds in it!  The rest were what we called “boat” beds: little plastic boat-like forms set on the floor with a plastic-covered foam mattress.  The mattress was about 4 inches above the floor.  For anyone older or with mobility problems, they were hell to get up out of.  Many of these patients needed extra hydration, so there they were, 4 inches above the floor, with an IV running!

              I have no idea who, but someone above my rank and pay grade, decided that they should give a reporter a tour of this infirmary.  He actually thought that seeing all these patients just about on the floor with IVs running, going through alcohol withdrawal, would make a good impression!  Everyone was ordered to cooperate with the news media.  Needless to say the reporter was horrified, not favorably impressed, and this tour led to an investigative series on medical care in the prisons that ran for several weeks!  I got out of the state just before the first article came out. 

              First time I ever had a moving van with professional movers, in all the moves I had made.  When they showed up, I was still packing.  Finally, the van left.  Then there were two kids, me, my best friend who was helping me move, two dogs (fortunately small ones), a cat and a parakeet to cram into the minivan, with our overnight luggage, since I knew I was not making this trip in a day.  I had to leave all my plants sitting on the curb, since there was no more room in the car.  We didn’t get on the road till 6 PM!  We stopped overnight at Harper’s Ferry.  It took a bit to find a motel that would take the animals and had two rooms available late at night.  We had to have the two rooms because I had to set up a litter pan for the cat, so I could let poor Henry out of his carrier.

              We got down to the new house in Brentwood after dark the next day (I am not a fast driver; anyone who has ridden with me will tell you that), only to find out that the electricity wasn’t on, which meant no AC, and it was June and hot.  So we spent another night in a motel.

              Next day we went to the house.  The mover showed up with the furniture, but his crew didn’t!  There was a community yard sale that day, so the driving made the rounds of it and hired a high school kid to help him unload the truck. 

              The moving man/truck driver was in his 40’s or 50’s, with lots of experience on the job.  He would not stop though.  He said if he stopped to eat or rest he couldn’t get going again.  We all helped with the small stuff, but there was a fair amount of big stuff, some of which had been taken apart and had to be put together. 

              The mover had a melt-down about 8:30 pm.  He couldn’t find the hardware to put Diane’s bed together and he just lost it.  Called the crew that had loaded the truck in Delaware and screamed at them.  We told him to go.  If we had to, we would get new hardware from the manufacturer.  We did find the hardware, not that summer but the next.  It was inside the charcoal grill!

              We didn’t find the hardware inside the charcoal grill that first summer because I never opened the charcoal grill!  I started the new job!  Which meant “Road Trip!”  It took almost 8 hours to get to Northeast Correctional Center in Johnson City and 6 hours to get to Northwest in Tiptonville.  First thing I needed to do was meet all these doctors and practitioners I was supposed to supervise!  I visited all the Nashville area prisons in the first two weeks, then the administrator, the nursing supervisor, Dr. K (part owner of the company and I took off to visit all the other facilities and meet everybody.

              Unlike Delaware, the state was too big to get the doctors to meet every month, so I had to settle for conference calls.  Basically, the job was the same as in Delaware: a large part of it was reviewing requests for outside consults and non-formulary medications, reviewing all the hospitalizations, reviewing charts and preparing reports on inmates who had died.  Inmates went to hospitals all over the state, which ultimately meant another road trip, to 26 different hospitals. 

              I was having fun with it, but my kids weren’t.  Nerissa didn’t drive yet and was stuck at the house in Brentwood for the summer.  We hadn’t had tornados in Delaware.  Three times that first summer I had to come home to get Nerissa out of the crawl space in back of the garage after the tornado warnings went off.  New neighborhood, no friends, two miles from the mall, nothing much to do.  I was being challenged; Nerissa was bored out of her skull.  Then school started and things went from bad to worse for Nerissa.  Ravenwood was a very white school.  The few black kids that were there teased Nissa because she didn’t do her hair (just wore it as an afro) and because she talked “white”.  The white kids didn’t care about her hair, but they didn’t like the “talking white” either.  As Nerissa tried to explained, it wasn’t “white” talk; it was northern talk.  She was a Yankee.  They didn’t care.  She was miserable.  Surrounded by kids her own age, she still had no friends.

              The realtor who sold us the house had given us a gift card for Chaffin’s Barn Dinner Theater.  We finally used it in October.  The play was a comedy about a young man, living with his parents while he finished up college, who wanted to move to Seattle when he graduated, and all the trouble he had communicating that.  It hit too close to home.  Diane (who was going to Nashville State) and Nerissa were both miserable.  Diane informed me she was going to go back to Delaware and camp in our old house, which hadn’t sold yet.  Nerissa wanted to go back and live with friends and go to high school in Delaware.  These were the kids who said “Go for it, Mom!” when I first discussed the move with them!  I sobbed into my dinner plate all through the comedy performance.

              Diane was 19.  She said if she went back she would register at the community college in Georgetown.  I felt I had to let her go.  Nerissa though, was 15, and she wasn’t going anywhere!  I cried myself to sleep for a bit but was enjoying the challenge of administration rather than hands on practice.  I tried to talk Nerissa into changing schools but she didn’t want to.  Things got worse for her before they got better, which is a whole other story.  Took till the middle of her junior year for things to improve for her.

            Diane came back in February with Sam, her high school boyfriend who had just finished his National Guard Training.  They lived with me.  Di got pregnant, they got married, and I had my first grandchild.  So as it turned out, stepping up into management in a state with 17,000 inmates, 40 providers and 14 major facilities, which I had no idea how to do, was challenging and fun.  But the real challenges were in parenting (which I also had no idea how to do): getting kids educated, helping one get past the bullying, having the other make me a grandmother.  And that turned out to be the role I had waited for all my life!