After months of queries and concerns about health care at the Pima County jail — from Arizona Luminaria, other media outlets and the public — the county has addressed some of the issues in a recent memorandum.
Currently, people detained in the jail receive their health care from an Alabama-based, for-profit medical provider, NaphCare, which the county has contracted for $1.5 million a month. NaphCare is the sixth vendor the county has contracted over the last 20 years.
“Health care delivery is challenging, expensive and complex regardless of setting,” the memo reads. “Health care delivery in the detention setting is even more difficult regardless of who is delivering the care.”
Released on Nov. 7 by county administrator Jan Lesher, the memo details the history of NaphCare’s work in the jail, problems with understaffing, the challenges of providing health care in a carceral setting, how the county oversees NaphCare’s performance and the ongoing problem with a high rate of deaths in the jail, among other issues.
Despite claiming that NaphCare is performing better than previously contracted providers and highlighting a “Facility of the Year” award granted to the jail this year by the National Commission on Correctional Health Care, the memo acknowledged the deaths in the jail, as well as the steep challenges NaphCare faces.
So far this year, at least eight people have died while being held in the jail. Another ten people have died in 2023 within 30 days of being released from the jail, according to data provided to Arizona Luminaria by the Pima County Office of the Medical Examiner.
“In my field the body count is what matters,” Dr. Francisco García, the deputy county administrator, told Arizona Luminaria.
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The memo substantiates many of Arizona Luminaria’s previously published findings, especially in regard to staffing shortages and financial penalties.
“This complexity and difficulty” of providing medical care in jail, the memo notes, “should not deter the County from setting high performance standards for our contractors and ourselves.”
The memo lays out that complexity in detail: “Greater than 80% of the adult population have a chronic condition ranging from cardiovascular to cancer,” according to the memo. “Almost 40% have some form of substance use disorder and greater than 50% have a mental health condition requiring medication. Moreover, a disproportionate share of this population, 20%, have an infectious disease, many without symptoms or prior detection, who require treatment.”
Arizona Luminaria has published two in-depth investigations focusing specifically on health care in the jail. The investigations were based on interviews with more than a dozen people who have been detained in the jail, five former NaphCare employees, and an extensive review of county audits of NaphCare’s performance. Taken together, the sources paint a portrait of serious lapses in care and delays in the delivery of medication — both of which contribute to dangerous and sometimes deadly conditions.
A lawsuit filed against NaphCare — as well as against Pima County Sheriff Chris Nanos and individual jail guards — by the family of 18-year old Sylvestre Inzunza who died of a fentanyl overdose in the jail in February of 2022 claims that NaphCare is responsible for “systemic failures” in providing medical care and was “grossly negligent.”
Complaints of delayed care continue today, according to multiple sources currently detained in the jail.
A NaphCare spokesperson said in a Nov. 29 email to Arizona Luminaria, “Regarding the claims of delays in care, we do not have evidence of that happening.”
They added: “NaphCare’s mission is to improve and save lives. We aim to ensure that every patient we treat within the Pima County Detention Center receives community standard of care to support a healthy return to their community.”
Despite the consistent and ongoing problems NaphCare has faced, Dr. García, the deputy county administrator, told Arizona Luminaria that they are the best provider the county has worked with in recent years. García oversees the Behavioral Health department, which in turn oversees the county’s contract with NaphCare.
“I have three medical contractors under my belt,” García said. “Are they, NaphCare, doing better than other contractors? Absolutely, but they can improve.”
Mia Burcham, an organizer with No Jail Deaths, told Arizona Luminaria, she has ongoing concerns about medical care in the facility.
”The county’s assessment of NaphCare makes plain how dire conditions are inside the Pima County jail, and how unlikely these conditions are to change,” Burcham said. “When the health care provider horrifically fails incarcerated people and maintains its contract, it means that continuing to send people to this jail, sending an increasing number of people to this jail, is a public health crisis.”
Understaffed
Arizona Luminaria identified staffing levels as a significant problem in early August, looking specifically at October 2022, noting that in that month the county hit NaphCare with its largest financial penalty since the company took over medical care, withholding $366,000 from its expected monthly payout of $1.5 million — docking it nearly 25%.
The recent memo echoes the same conclusion, but notes that penalties for staffing have decreased since then. “Although still not perfect, there has been demonstrable improvement in staffing,” the memo notes.
“Naphcare has struggled to meet the contracted staffing requirements since their engagement,” the memo reads, attributing the shortages to the COVID-19 pandemic and Pima County’s “overall shortage of health care providers especially in the area of behavioral health.”
The memo notes that before hiring a new medical director, Dr. Ravi Shah, in July of this year, NaphCare had gone through three previous directors, including a six-month vacancy period, in less than two years of operating in the jail.
Noting that the directorships have now been filled, the memo states, “With a fully staffed, dedicated and strong on-site leadership team it is anticipated that additional progress will be possible in a relatively expedient manner.”
A NaphCare spokesperson, on Nov. 29, also addressed problems with staffing: “As is the case across the country for healthcare organizations, we recognize that staffing is an ongoing challenge. We’re investing in innovative workforce strategies designed to solidify staff levels.”
Given the high turnover rates and difficulty in fully staffing the jail, one option for improving care that other jurisdictions, as well as local critics, have floated is resorting to the county itself providing health care to people in the jail.
“I do know it would be more expensive” to go with in-house care, García said. When asked if lawsuits filed against the county — taking into account attorney fees and potential settlements — were factored into that calculus, García said they weren’t, but that “having a contractor provide care offers a certain amount of insulation from these claims.”
“It separates our exposure as these things happen,” he said.
García stressed that maintaining proper staffing levels would be significantly harder without relying on a private contractor. He said there have been recent moments when a position has been vacant and he’s been able to call NaphCare to insist that they move someone from another facility to fill that vacancy, and they’ve quickly complied. He said that such a move wouldn’t be possible if the county itself was providing the medical care.
Pima County Supervisor Matt Heinz, of District 2, is a longtime physician at University of Arizona and Tucson Medical Center. He has also worked for the White House leading federal health care reform. Heinz told Arizona Luminaria on Nov. 21, “The county is failing through NaphCare. We’re not doing what we should be doing.”
Heinz explained that private, for-profit vendors such as NaphCare worry about the bottom line. “That’s a business,” he said, “that’s how businesses run. But we’re not a business,” he said, in reference to the county. Heinz said that bringing medical care in the jail back “in-house” would let them focus on improving care.
Heinz said that he is planning on asking to have a public discussion with the other supervisors, but didn’t specify a date. He said that ensuring better medical care “seems like a much better use of $400 million dollars,” referencing the estimated cost of building a new jail.
County expecting an ‘increase in mortality‘
In August, for an investigation into NaphCare’s performance in the jail, the county provided Arizona Luminaria with corrective action plans, implemented by the county after persistent shortcomings in care.
Not all of the corrective action plans, which include follow up assessments, given to Arizona Luminaria were complete. García, while not sharing specifics of the outcome of the plans, said that the county has focused on particular performance areas such as response times to medical requests (commonly referred to as “kites”) and has worked hard to “remove administrative barriers for those seeking care” in the jail.
He stressed that “responses to kites need to be succinct and effective.” García characterized the county and NaphCare’s response to the previous performance shortcoming as a win. “Our data says we have gotten better.”
García said that when people file grievances about delays in delivering prescribed medications or answering sick call requests, the county is aware and follows up on them.
“We are being fairly timely in terms of getting people onto their medications. There are legal reasons why sometimes they don’t, like medical records haven’t been transferred. I’m sure that sometimes it’s not as timely as it needs to be,” García said.
Arizona Luminaria continues to hear about significant delays in answering sick call requests. The mother of one man in the jail on a parole violation said her son had filed more than a dozen requests to be seen by mental health. As of Dec. 1, he had not been seen for over six weeks, according to his mother. Fearing reprisals, both mother and son asked not to be named.
The memo also notes that officials expect, especially given the arrival of the deadly drug xylazine, or “tranq,” to the county and region, an “increase in mortality” in the jail.
García said that they have identified only one verified case of tranq in Pima County, though community members and advocates suspect there are more. “It may be a matter of months or less until we see more,” García said.
”We anticipate that additional specialty wound care nurses and facilities may be needed in the near future to care for these detainees,” the memo reads.
Officials ask for a bigger jail
According to a forecast made by the county’s Blue Ribbon Commission analyzing the need for a new and bigger jail, the number of people the county plans to detain in the next twenty years will increase by more than 50%, to 3,160. That’s up from an average daily population of just over 1,900 today.
In a separate memo, the Blue Ribbon Commission asked the county’s Behavioral Health Department if the medical unit was properly sized and equipped to deal with the expected increase of detentions. The answer was no. The same question was asked about mental health — if the unit was properly sized and equipped to handle a larger population. The answer was also no.
Paula Perrera, the Behavioral Health Director, said in the memo: “Unfortunately, older increasingly disabled and chronically ill populations should be expected.”
By all accounts, the number of people locked up in the jail will grow and their medical needs will be more complex. The Nov. 7 memo notes that the many pre-existing medical conditions “may be exacerbated by detention and the trauma of diminished contact with family and friends, loss of employment, and uncertainty of their prosecution.”
That passage from the memo was recently cited at a board of supervisors meeting on Nov. 21 by Liz Casey, a social worker and organizer with No Jail Deaths. Casey spoke during the call to audience session at the meeting, saying that medical care in the jail is forced to “contort itself to fit within a fundamentally harmful system.”
“The memo makes plain that healthcare cannot be provided in a carceral setting, and that the provision of care within the Pima County Jail is horrifically inadequate, yet notes that not much can be done,” Casey said.
The county is currently seeking to address both of those challenges — considering building a new and bigger jail and reassessing the way it provides health care.
The Blue Ribbon Commission tasked with studying the need and feasibility of a new jail, is set to launch a public survey on Dec. 26 and finalize a report to the county’s board of commissioners by the end of January.
There are other approaches, critics contend. One of those is focusing on decarcerating, sending fewer people to jail, and the other is improving medical and mental health outside of the jail setting.
“The county acknowledges that the trauma of incarceration worsens health outcomes and that care is difficult to deliver around the precarious conditions of incarceration,” Burcham, of No Jail Deaths, said.
“It is Pima County’s expectation that the care delivered in the County’s facilities should meet or exceed the care available in the community, within the limitations inherent in a jail setting,” according to the memo.
Burcham and others counter, however, saying that those limitations are too steep. “What people need are community-based services that support long term health and stability, not to be sent through a revolving door where people disproportionately in need of medical intervention don’t reliably receive it.”
Ultimately, she says, “We need to stop sending people to this jail in the first place.”
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