Nebraska prison system's medical director denies medical requests at higher rate than predecessor
YORK 鈥 In March, a 75-year-old woman incarcerated at Nebraska鈥檚 only women鈥檚 prison was surprised to discover a troubling note tacked onto one of her medical records.
Wilma Castor had just begun seeing a specialist for a severe toe wound that caused her foot to swell so much she could barely walk, let alone work.
The wound care specialist, Dr. David Voigt, suspected Castor had an embolus 鈥 a blockage in a blood vessel 鈥 on her toe. Among other recommendations, he suggested Castor have an echocardiogram, a heart ultrasound, to 鈥渞ule out a cardiac source鈥 for the embolus, according to medical records, which Castor shared with the York News-Times.
But Castor never received the echocardiogram. Instead, she was told that the prison system鈥檚 medical director believed the procedure was unnecessary. The director鈥檚 decision prompted Voigt to write the note at the bottom of a checkup document, taking issue with it.
鈥淭he medical director at the prison has denied her an echocardiogram to rule out a cardiac source for the emboli. I feel that this should be done to complete the workup, but the patient obviously can鈥檛 get access to it if it was denied by the prison,鈥 Voigt wrote.
The medical director鈥檚 response to Castor鈥檚 request for an echocardiogram wasn鈥檛 an isolated incident.
The denial or deferral of essential medical procedures, such as cancer screenings and heart tests, is increasingly common within Nebraska鈥檚 prison system under the new medical director, Dr. Jerry Lee Lovelace Jr., according to thousands of inmate requests for medical procedures and consultations with specialists received by the prison system鈥檚 medical directors between January 2021 and June 2024. The data is not available after June because the department stopped making it publicly available.
Lovelace鈥檚 willingness to deny specialists鈥 recommendations, such as the recommendation from Voigt, marks a departure from the previous director, Harbans Deol, who told the York News-Times he could not recall ever denying the recommendations of outside specialists.
The denial and deferral rate of medical consult requests was about 15 times higher during the first seven months of Lovelace鈥檚 tenure than during the last 25 months of Deol鈥檚.
Lovelace鈥檚 denials or deferrals included critical cancer screenings like colonoscopies and mammograms, along with orthopedic and dental care, spanning nearly all of the department鈥檚 facilities and prompting concern from incarcerated individuals and advocates. None of the requests are related to mental health care, which is handled internally and does not require review by the medical director, Lovelace said.
鈥淭he significant increase in denial of requests for typical medical care is very concerning and could leave hundreds of people at risk of worsening health or death,鈥 said Dr. Will Weber, medical director at the prison health advocacy nonprofit Medical Justice Alliance, after reviewing the data. The organization is a nationwide group of volunteer physicians who review medical records for incarcerated people to evaluate their medical care.
鈥淢edical providers at the facilities rely on these requests to provide care for patients when medical staff lack the resources or specialty care needed to meet health needs,鈥 Weber said, adding that many of the requests that Lovelace denied or deferred seemed reasonable and aligned with national guidelines of care.
Between Jan. 1, 2021, and Feb. 1, 2023, Deol denied or deferred around 1.1% of medical consult requests, according to the department鈥檚 data. Between Oct. 30, 2023, and June 2, 2024, Lovelace denied or deferred around 16.5%.
Dr. Jefferey Kasselman, who served as interim director after Deol鈥檚 last day on Feb. 1, 2023, and before Lovelace started on Oct. 30, 2023, denied or deferred about 1.9% of requests.
The rates are based on over 10,000 requests for medical procedures and specialist consultations received by the department between January 2021 and June 2, 2024, and provided to the News-Times. Lovelace confirmed that his approval rate was about 83%, while Deol鈥檚 was about 99% and Kasselman鈥檚 was about 98%, based on the records.
There is no data available after June 2 鈥 about two months after the News-Times first asked the department for the data 鈥 because in June the department switched to an electronic medical records system and no longer maintains a spreadsheet with the consult requests, Lovelace said. All consult requests are now considered a part of an inmate鈥檚 file and therefore confidential and exempt from public disclosure by state law, according to the department鈥檚 public records manager.
Lovelace declined to give an in-person or phone interview, but in emailed statements he outlined his process for reviewing the requests and answered questions. He said he 鈥渃annot speak to the process used by the previous medical directors at NDCS.鈥
He said his review process for consult requests is 鈥渂ased on medical necessity, community standard of care and InterQual criteria 鈥 evidence-based guidelines used by health care organizations to assess the appropriateness of clinical care.鈥
To see prison medical staff, Lovelace said, incarcerated individuals first submit a form that is reviewed by a nurse. If appropriate, the nurse refers the individual to the facility鈥檚 health provider. The health providers may be doctors or nurse practitioners, depending on the facility.
If the prison鈥檚 health providers feel that an individual needs outside medical care, they can submit a 鈥渃onsult鈥 request to the prison system鈥檚 medical director. The medical director reviews thousands of these consult requests every year.
The state prison system provides care for about 5,800 people, according to a 2024 report from the Inspector General鈥檚 Office. Incarcerated individuals at the 275-bed women鈥檚 prison have their care is sometimes delayed or denied by on-site medical providers well before a provider submits a consult request, which could be delayed or denied by the medical director.
The provider at the women鈥檚 prison, Xann Linhart, an advanced practice registered nurse, submitted a consult request for Castor to see Dr. Voigt. Then another consult request had to be submitted in order for Castor to receive the echocardiogram. Linhart did not respond to an email asking for an interview.
Lovelace said he gives consult requests four assessments: approval, partial approval, need additional information or an alternative treatment plan.
Castor鈥檚 request for an echocardiogram, based on Voigt鈥檚 recommendation, appears to have been assessed as 鈥淣MI,鈥 or, needing more information, and marked 鈥渄eferred鈥 by Lovelace, according to the consult data.
Identifying information in the consult data is redacted, so it is impossible to say with absolute certainty that the deferred Feb. 1, 2024, request for an echocardiogram from the women鈥檚 prison is Castor鈥檚, but the timing lines up with her medical records. Even though the procedure was technically 鈥渄eferred,鈥 Castor said during an in-person interview that she never ended up receiving the echocardiogram. She said she has received some treatment for the toe wound.
The consult requests marked 鈥渄enied鈥 are usually the ones assessed by Lovelace as 鈥淎TP鈥 or needing alternative treatment plans. For instance, a request from a provider at the Work Ethic Camp in McCook for an individual who needed a steroid injection behind his knee was denied by Lovelace, who suggested an alternative treatment plan, writing, 鈥渢his can be performed on-site. Will schedule a visit when several injections needed.鈥
An alternative treatment plan is 鈥渞arely a denial of medical services,鈥 Lovelace said in his email to the News-Times. If a provider disagrees with an alternative treatment plan, Lovelace said, the provider calls him and they discuss the case. 鈥淲e work to arrive at a decision best for the patient.鈥
Some incarcerated individuals and advocates, though, expressed concern that requests for medical care were being wrongly deferred or denied under Lovelace.
Before coming to Nebraska in October 2023, Lovelace worked for Centurion and Corizon, two private, for-profit prison health care providers in Missouri. Corizon has faced scrutiny in the last year after it filed for amid numerous medical malpractice lawsuits.
While in Missouri, Lovelace was the subject of a handful of federal lawsuits over denial of care. One lawsuit, which is ongoing, alleges that in 2021 while working as a regional director for Corizon, Lovelace declined to approve shoulder replacement surgery after it was recommended by two orthopedists because he found there was 鈥渋nsufficient information provided to determine the necessity for shoulder replacement.鈥 As regional director, the lawsuit says, Lovelace was in charge of approving medical appointments and specialty treatment outside the prison.
Lovelace denied the allegation in a filing and said in an email to the News-Times he could not comment on pending litigation.
State Sen. Terrell McKinney of Omaha, who has advocated for prison reform bills in the state Legislature, said he has concerns about the new medical director. He said in a phone interview that his office had heard from family members of incarcerated individuals about problems getting specialty care under Lovelace.
Holly Liner, who is incarcerated at the women鈥檚 prison in York, wrote in an email that it took her months to get a request for a mammogram approved after she found a lump in her breast.
Aron Boyd, 50, who is incarcerated at the Community Correctional Center in Omaha, wrote that he was denied a colon screening and a prostate screening by Lovelace even though, as a Black man, Boyd is supposed to have both of those screenings starting at age 45. 鈥淚 am told I do not qualify due to the medical director鈥檚 preference to wait to around the old standard of 55,鈥 Boyd wrote in an email.
Lovelace told the News-Times his policy was to start those screenings at age 45 or at 40, if there is family history. But Boyd said he never received either procedure and was explicitly told it was because of department policy. 鈥淲hoever this director is isn鈥檛 interested in giving proper care,鈥 Boyd wrote.
Boyd said he was surprised by the department鈥檚 approach to his medical care given that in 2019 he won a $115,000 against the department after being ignored by medical staff while having a heart attack. Since then, he said, he has still struggled to get approved to see a cardiologist.
In response to another question about the increase in denied consults during his tenure, Lovelace again wrote that his process is based on medical necessity, community standard of care and InterQual criteria.
But Weber pointed to medical consult requests that appeared to align with national guidelines, yet were denied by Lovelace.
A patient with anemia was denied a colonoscopy to look for intestinal cancer, despite strong national guidelines that a colonoscopy should be performed, Weber said, based on the consult data. In another request, Weber said a radiologist 鈥 a specialist in medical imaging 鈥 recommended a CT scan of a patient鈥檚 spine due to concerning findings on the X-ray, but this was denied without justification.
鈥淒enying reasonable requests undermines the medical judgment of the providers seeing the patients, leaving (providers) unable to access the care their patients need and that the providers feel unable to provide,鈥 Weber said.
Deol, who served as medical director between 2017 and 2023, said that during his first year he spoke by phone weekly with the providers at every facility to go over all of the consult requests. In subsequent years, he said, he mostly made the decisions on his own, but like Lovelace, he said, he sometimes called the provider to discuss the consults.
He declined to comment on the increase in denied and deferred consults since Lovelace took over.
But Deol seemed to draw a distinction between denying a consult request from a prison medical provider and denying a request recommended by an outside specialist, such as Voigt.
鈥淚 don鈥檛 know if I ever really denied a specialty procedure if they felt it was necessary,鈥 Deol said in a phone conversation with the News-Times, referring to a recommendation by an outside specialist, such as Voigt鈥檚 recommendation of an echocardiogram. Voigt did not respond to phone calls made to his home and office phones.
Lovelace said he does not draw such a distinction. 鈥淢y decision depends on the amount of information supplied by the provider, which allows me to make an informed decision,鈥 he wrote.
Concerns about medical care in Nebraska鈥檚 prisons long predate the arrival of Lovelace.
In 2017, about the time Deol started his job, the ACLU and other organizations filed a lawsuit against the prison system over its medical care. Deol told the News-Times the department tried to improve care in response to it. Sen. McKinney was critical of Deol, as were some formerly incarcerated individuals who spoke with the News-Times. The lawsuit was ultimately dismissed.
Since then, Nebraska鈥檚 prison population has grown. It is also , and according to a September from the state inspector general, about half of the prison system鈥檚 nursing jobs are not filled. One facility with well over 500 inmates has no full-time primary doctor on staff, in violation of state statute.
The Nebraska Department of Corrections is not accredited by the National Commission on Correctional Health Care, a voluntary program that sets national prison health standards and reviews department practices for compliance, according to Robert Simon, the program鈥檚 director of accreditation. The program does not specifically look at the denial or deferral rate of consult requests, Simon said, though it does review the departments鈥 process of receiving and responding to medical consult requests.
With no more public access to the data, it is unclear what the denial or deferral rate of consult requests has been under Lovelace since June.
After the department decided to deny a public records request for medical consult data after June 2, the Attorney General鈥檚 Office, which reviews appeals of public records requests, affirmed the decision.
Though consult data has been stored by the department in a publicly accessible way for years, Assistant Attorney General Leslie S. Donley said there was no statutory requirement for the prison system to do so.
鈥淲e realize the (Nebraska Department of Correctional Services) previously compiled inmate consult and procedure requests in a spreadsheet and made that spreadsheet available to you (with redactions). However, we are unaware of any statute that requires the NDCS to continue to create the spreadsheet,鈥 Donley wrote.
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Lee Enterprise reporters Mike Brownlee and Lauren Cross contributed to this story.