February 19, 2008

MEMORANDUM FOR	RAYMOND J. BEAUDET ASSISTANT INSPECTOR GENERAL FOR AUDIT OFFICE OF THE INSPECTOR GENERAL
FROM:	Harley G. Lappin, Director Federal Bureau of Prisons
SUBJECT:	Response to the Office of Inspector General’s (OIG) Draft Audit Report: The Federal Bureau of Prisons’ Efforts to Manage Inmate Health Care

The Bureau of Prisons (Bureau) appreciates the opportunity to comment on and respond to the recommendations from the OIG’s draft audit report entitled The Federal Bureau of Prisons’ Efforts to Manage Inmate Health Care.

We are requesting OIG’s Statement on Internal Controls, Finding I, Page 55, stating the Bureau “did not provide necessary medical care to inmates,” be removed from the report. We do not believe it accurately portrays the state of medical care in the Bureau. While the Bureau strives for 100% compliance with its policies and guidance, it is unrealistic to expect such results. The audit was based on the Clinical Practice Guideline, “Preventive Health Care,” which was adapted from recommendations of the U.S. Preventative Services Task Force. This guideline is a recent issuance that emphasizes the importance of prevention in order to avoid disease. Full implementation is a long-term effort and discretion is accorded to providers to ascertain medical priorities within the prevention model. The Bureau fully anticipated it would take a period of years to achieve full implementation. The Bureau is glad OIG focused on the Bureau’s Preventative Health Care Guidelines because we are proud to have issued cutting edge guidance. However, the generalized statement that the “Bureau is not providing necessary medical care to inmates” is an unfortunate view which fails to take into account that while prevention is a desirable goal, in balancing health care needs, the Bureau must place priority on lifesaving measures and care.

Please find below listed the Bureau’s response to each individual recommendation:

Recommendation #1: Establish procedures for collecting and evaluating data for each current and future health care initiative to assess whether individual initiatives are cost-effective and producing the desired results.

Response: The Bureau agrees with this recommendation and will establish protocols for collecting and evaluating data. We are not a stand-alone healthcare service and unlike the private sector, our health services are delivered within the constraints of a correctional environment.

For those initiatives for which we have or can collect hard data, we will make every effort to assess cost-effectiveness. For example, in our third-party bill adjudication initiative, we will be able to measure cost pre- and post-contracting beginning in FY2008. For some of our initiatives, it will not be feasible, however, to create or retrieve data to use in cost comparisons. Also, not all initiatives are intended to produce cost savings. Certain initiatives do not generate cost savings, but promote better medical outcomes and continuity of care.

Recommendation #2: Review the medical services that the OIG and the BOP’s Program Review Division identified as not always provided to inmates and determine whether those medical services are necessary, or whether the medical service requirement should be removed from the clinical practice guidelines.

Response: The Bureau agrees with this recommendation. In January 2008 we reviewed all of the Bureau’s Clinical Practice Guidelines. Based on that review, certain guidelines have been identified for revision (http://www.bop.gov/news/medresources.jsp). We will highlight quarterly reports from Program Review Division in on-line training sessions with Health Services staff, the first of which will take place in April 2008.

Recommendation #3: Issue clarifying guidance to the institutions regarding the medical services that BOP decides are necessary for BOP medical providers to perform.

Response: The Bureau agrees with this recommendation and will issue guidance to institutions underscoring the importance of the Clinical Practice Guidelines. This will be completed by April 1, 2008.

Recommendation #4: Strengthen management controls to ensure proper administration of BOP medical contracts by providing guidance and procedures to all BOP institutions for:

1. reviewing contractor invoices for accuracy,
2. ensuring contractor invoices are supported by adequate documentation,
3. ensuring that invoice discounts are properly applied,
4. ensuring that contractor performance reports are complete and accurate, and
5. ensuring that contractor timesheets are verified by a BOP employee.

Response: The Bureau agrees with this recommendation and will issue guidance to all Bureau Contracting Officers and Health Services Administrators regarding Medical Contract Administration procedures. Guidance will be completed and distributed by April 1, 2008.

Recommendation #5: Develop a process to use the program summary reports prepared by the Program Review Division to develop or clarify agency-wide guidance on systemic deficiencies found during program reviews.

Response: The Bureau agrees with this recommendation and will issue guidance regarding systemic deficiencies found during program reviews through periodic on-line training sessions, the first of which will begin in May 2008.

Recommendation #6: Ensure initial privileges, practice agreements, or protocols are established for all practitioners, as applicable.

Response: The Bureau agrees with this recommendation and will issue guidance clarifying to institutions the importance of ensuring that applicable privileges, practice agreements, protocols, and peer reviews are handled in a timely manner, and the potential consequences of failure to do so. Guidance will be issued by April 1, 2008.

Recommendation #7: Ensure privileges, practice agreements, and protocols are reevaluated and renewed in a timely manner.

Response: See response to Recommendation #6.

Recommendation #8: Ensure that practitioners are not allowed to practice medicine in BOP institutions without current privileges, practice agreements, or protocols.

Response: See response to Recommendation #6.

Recommendation #9: Ensure that peer reviews of all providers are performed within the prescribed timeframes.

Response: See response to Recommendation #6.

Recommendation #10: Until the training program on accumulating and reporting performance data is implemented, issue guidance to all institutions on how to accumulate and report data for the health care performance measures to ensure consistency in the way institutions collect and report performance data. Once the training program is fully developed, ensure that appropriate institution staff receive the training.

Response: The Bureau agrees with this recommendation. Guidance will be issued to all institutions by May 1, 2008, on how to accumulate and report data for the health care performance measures to ensure consistency in the way institutions collect and report performance data. Data collection and reporting will also be addressed in on-line training.

Recommendation #11: Establish a process for reviewing the health care performance measures reported by institutions that includes actions that will be taken when institutions are not meeting the target performance levels.

Response: The Bureau agrees with this recommendation and has a process in place to assess performance measures. A memorandum was issued on February 12, 2008, to all Bureau wardens, notifying them of changes to the national performance measures and reiterating the policy requirement to collect and report these measures. An on-line training session for institution Health Services staff was conducted February 13, 2008, to discuss the changes and the reporting requirements. The Health Services Division’s Office of Quality Management will be collecting and reviewing this data semiannually and reporting to the regional medical directors when institutions are not meeting the expected target levels. Each regional medical director will ensure that national performance measures are addressed at each institution under his or her oversight. Regional medical directors will assess target level failures, provide recommendations for improvement, and follow-up during Clinical Director Peer Reviews.

If you have any questions regarding this response, please contact VaNessa P. Adams, Senior Deputy Assistant Director, Program Review Division, at (202) 616-2099.