The Federal Bureau of Prison's Efforts to Manage Inmate Health Care

Audit Report 08-08
February 2008
Office of the Inspector General

Appendix II
BOP Initiatives since FY 2000 to Improve the Effectiveness
and Efficiency of Inmate Health Care
Initiative Description
  1. Medical Designations Program
This initiative involves: (1) assigning each inmate a care level from 1 to 4, with 1 being the healthiest inmates and 4 being inmates with the most significant medical conditions; (2) assigning each BOP institution a care level designation from 1 to 4 based on the care level of inmates the institution is staffed and equipped to handle; (3) staffing each institution based on its designated care level; and (4) moving inmates between institutions to match each inmate’s care level to the care level of the institution.
  1. Medical Staff Restructuring
Under this initiative, the BOP established staffing guidelines for Care Level 1, 2, and 3 institutions. Because the existing staffing of the institutions did not always match the care level staffing guidelines, the BOP had to move medical staff throughout the BOP to implement the guidelines. Institutions that had staff in positions contrary to the guidelines were required to either move the staff to another facility or reassign the staff to another authorized position in the facility.
  1. Tele-medicine
This initiative involves the remote delivery of health care using telecommunications technologies, such as video-conferencing.
  1. Electronic Medical Records
This initiative involves automating the medical records for inmates. The initial system included the capability to: (1) track comprehensive history and physical examination information, (2) schedule inmate medical visits when required, and (3) track medical-related supplies and equipment issued to inmates. The BOP subsequently added a pharmacy module to the system to manage the medications provided to inmates.
  1. Medical Claims Adjudication
This initiative is designed to ensure the BOP properly pays medical claims and complies with requirements of the Prompt Payment Act. In April 2004, the BOP began researching the feasibility of using third-party medical claims processing services. The BOP developed a Statement of Work defining its requirements for medical claims adjudication services and in July 2006, the BOP issued a Request for Information asking interested commercial vendors to submit specific information about the claims processing services they provide. From July 2006 to September 2007, the BOP refined its requirements and finalized the Statement of Work in September 2007. The BOP expects to award a contract for the medical claims adjudication services early in calendar year 2008.
  1. Medical Reference Laboratory
In 2001, the BOP established a Medical Reference Laboratory (MRL) system at the: (1) United States Medical Center for Federal Prisoners, Springfield, Illinois; (2) Federal Medical Center, Rochester, Minnesota; and (3) Federal Medical Center, Butner, North Carolina. This initiative was designed to contain or reduce health care costs by enabling non-medical facilities within the BOP to collect and ship specimens to one of the three MRLs, where the laboratory tests could be performed at a lower cost than through individual contracts throughout the country.
  1. Medical Equipment
The BOP implemented this initiative in 1997 requiring that a senior official at BOP headquarters approve all purchases of medical equipment with a single item value of more than $1,000. BOP subsequently raised the threshold to $5,000. To obtain approval, the requesting institution must submit a Major Equipment Justification and include evidence that the institution researched alternatives to find the best value for the equipment being acquired. This helps ensure that BOP institutions are not frivolous with equipment requests and spending. Under the initiative the BOP also consolidates like purchases submitted for approval, which permits better pricing on bulk purchases through one of the Department of Defense’s Defense Supply Centers. The Defense Supply Centers primarily purchase items such as food, clothing and textiles, pharmaceuticals, medical supplies, construction items, and other equipment to support the U.S. military. The centers also use their purchasing power to obtain such items for other federal agencies at a lower cost.
  1. Inmate Co-payment
This initiative was implemented in October 2005 and required inmates to pay a $2 fee when requesting certain types of medical evaluations. The BOP does not charge indigent inmates a co-payment fee. The BOP also does not charge inmates for certain medical services such as visits related to a chronic medical condition, preventive health visits, or evaluations related to pregnancy. The initiative was designed to reduce the number of unnecessary inmate initiated medical visits. A BOP analysis of data for the first year of implementation showed a significant decrease in the number of inmate initiated medical visits.
  1. Medical Coverage
In January 2005, the BOP discontinued the requirement for 24-hour on-site medical coverage at non-medical institutions. Instead of 24-hour on-site medical coverage, each institution is now required to have a plan in place for providing emergency and urgent care services to inmates consistent with American Correctional Association standards. The plan should include a team of first responders trained to use the automatic external defibrillator and perform cardiopulmonary resuscitation as clinically indicated. This change allowed institutions to reassign staff to the day shift when inmates require the most medical care. According to the BOP, the reduction in premium pay for the 8-hour overnight period that is no longer staffed resulted in significantly reduced staffing costs.
  1. Staffing Provider Teams
The BOP has traditionally provided health care to inmates based on a “military” model utilizing the concept of sick call and same-day treatment. Any available provider evaluated an inmate, and this led to “practitioner shopping” by the inmates, and inconsistency in the approach to treatment of episodic complaints. In 2005, the BOP began implementing the Patient Care Provider Team concept, where inmates are assigned to a primary provider team that manages both the chronic and episodic care of the inmate. This approach is designed to improve the consistency of treatment and eliminate the ability of the inmate to consume valuable staff resources by going from provider to provider for treatment for the same complaint. According to the BOP, implementation of provider teams has reduced duplicate diagnostic tests, consultations, and treatments.
  1. Federal Resource Sharing
This is an ongoing initiative through which the BOP has existing contracts with the Department of Veterans Affairs to obtain local medical services at the facility level, such as laboratory services, tele-medicine, HIV tests, and others. The initiative is designed to contain or reduce costs for these medical services by taking advantage of the “economies of scale” available through the Department of Veterans Affairs that are not available to the BOP or private sector laboratories.
  1. Health Promotion
In 2000, the BOP had a three-person team in its Health Services Division that worked on Health Promotion and Disease Prevention initiatives. In recent years, the BOP disbanded this team and the functions of promoting health within the inmate population were realigned to appropriate groups within the Health Services or other divisions. In 2005, the Health Services Division issued its Preventive Health Care Clinical Practice Guidelines outlining risk-based screening for inmates to identify and monitor those at risk for developing serious medical conditions such as diabetes, sequels of HIV infection, and heart disease. This initiative is designed to promote better health among inmates beginning at admission to the facility and continuing throughout the inmate’s incarceration. This guideline was revised in April 2007.
  1. Consolidation Pilot Project with the United States Marshals Service
This project was conducted in FY 2000 at three BOP institutions and was designed to determine the financial, personnel, medical, and other resources that would be necessary for the BOP to assume responsibility for medical services for the United States Marshals Service’s inmates housed in BOP facilities. The project was deemed successful and expanded to include the following BOP institutions: all existing Federal Medical Centers (FMC) in June 2000; the Brooklyn Metropolitan Detention Center (MDC) in May 2005; and the Guaynabo MDC, Fort Devens FMC, Seagoville FCI, and Atlanta FCI in October 2006. The Marshals Service reimburses the BOP for expenses incurred by the BOP for providing community-based medical care to the U.S. Marshals Service’s prisoners housed at BOP institutions.
  1. National Cardiopulmonary Resuscitation and Automated External Defibrillator Contract
This initiative is designed to provide cardiopulmonary resuscitation and automated external defibrillator training and certification to BOP health care staff through a nationally negotiated contract with standardized pricing. The BOP approved and submitted a Request for Contracting Action in May 2007 and the BOP expects to award the contract early in calendar year 2008.
  1. National Medical Air Transportation Contract
This initiative is designed to provide a single nationwide contract for medical air transportation services for all BOP institutions at standardized and best-value pricing. During FY 2007, the BOP conducted market research and issued a Request for Information. The BOP plans to award the contract during FY 2008.
  1. National Comprehensive Medical Contract and Preferred Provider Organization
This initiative is designed to provide a contract for health care services for all of the BOP’s institutions at standardized and best-value pricing. At the end of FY 2007, the BOP was conducting market research for this initiative.
  1. Catastrophic Case Management
This initiative is designed to: (1) implement a catastrophic case management system to provide clinical oversight and intervention of complex and specialized care cases, and (2) provide funding reimbursement to the institutions to mitigate the fiscal impact those cases have on the institutions’ medical budgets. As of the end of FY 2007, the BOP had drafted preliminary procedures and protocols for internal review and comment. The BOP anticipates submitting this initiative to the BOP’s Executive Staff for consideration in FY 2008.
  1. Mobile Surgery
This initiative is designed to provide a national contract for mobile surgery services at standardized and best-value pricing. The contract is expected to provide on-site surgical services through a mobile surgical unit in lieu of sending inmates outside of the institutions for surgery. The BOP formed a workgroup during FY 2007 and identified three institutions in the Southeast Region to pilot this initiative. Further implementation will be predicated on the success of the pilot, status of existing medical services contracts, and the ability of the contractor to expand the services to other BOP institutions.
  1. Magnetic Resonance Imaging, Computerized Axial Tomography, and Mammography
This initiative is designed to provide a national contract for magnetic resonance imaging, computerized axial tomography, and mammogram services at standardized and best-value pricing. The BOP began market research during FY 2007.
  1. Staffing and Recruiting
Through this initiative begun in FY 2007, the BOP is attempting to identify novel, unique, and unconventional strategies to recruit and retain health care workers, with the understanding that there is and will continue to be shortages of trained and qualified health care workers in the United States and worldwide.
Source: Data provided by BOP officials

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