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

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


The Federal Bureau of Prisons (BOP) is responsible for confining federal offenders in prisons and community-based facilities. As of November 29, 2007, the BOP housed 166,794 inmates in 114 BOP institutions at 93 locations. In addition, the BOP housed 33,354 inmates in privately managed, contracted, or other facilities.8

The BOP institutions include Federal Correctional Institutions (FCI), United States Penitentiaries (USP), Federal Prison Camps (FPC), Metropolitan Detention Centers (MDC), Federal Medical Centers (FMC), Metropolitan Correctional Centers (MCC), Federal Detention Centers (FDC), the United States Medical Center for Federal Prisoners (MCFP), and the Federal Transfer Center (FTC). When multiple institutions are co-located, the group of institutions is referred to as a Federal Correctional Complex (FCC). Some institutions are located within federal correctional complexes that contain two or more institutions. Appendix IX describes the various types of BOP facilities. Appendix V contains a list of the BOP institutions. The map below depicts the location of BOP facilities.

BOP Facilities

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Source: OIG mapping of BOP facilities based on data provided by the BOP

Health Care Responsibilities

As part of the BOP’s responsibility to house offenders in a safe and humane manner, it seeks to deliver medically necessary health care to its inmates in accordance with proven standards of care. This responsibility stems from a 1970s court case Estelle v. Gamble, in which the U.S. Supreme Court concluded that an inmate’s right to medical care is protected by the U.S. Constitution’s Eighth Amendment guarantee against cruel and unusual punishment.9 The Supreme Court concluded that “deliberate indifference” – purposefully ignoring serious medical needs of prisoners – constitutes the inappropriate and wrongful infliction of pain that the Eighth Amendment forbids.10

According to BOP Program Statement P6010.02 Health Services Administration, the BOP’s responsibility for delivering health care to inmates is divided among the following BOP headquarters, regional offices, and local institution officials.

Health Care Costs

The BOP funds inmate health care through its Inmates Care and Programs appropriation. The BOP does not budget a specific amount for health care services. As inmates require medical care, the BOP provides funding for these services and obligates funds for health care as expenses occur. From fiscal year (FY) 2000 through FY 2007, the BOP obligated about $4.7 billion to inmate health care. The following chart shows the BOP’s annual health care obligations during this period.

BOP Health Care Costs
FYs 2000 through 2007

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Source: BOP Budget Execution Branch

Controlling Health Care Costs

To control the rising cost of health care, since the early 1990s the BOP has implemented several initiatives aimed at providing more efficient and effective inmate health care. These initiatives include: (1) sharing health care resources with other federal agencies such as the Veterans Administration, (2) establishing medical reference laboratories within the BOP for routine laboratory analysis, and (3) obtaining medical equipment through the Defense Supply Center at General Services Administration pricing.

On-going BOP initiatives include: (1) assigning most inmates to institutions based on the care level required by the inmate, (2) installing an electronic medical records system that connects institutions, (3) implementing tele-health to provide health care services through video conferencing, and (4) implementing a bill adjudication process to avoid costly errors when validating invoices. We include a discussion of these cost-cutting initiatives and the effect the initiatives have had on controlling inmate health care costs in the Findings and Recommendations section of this report.

The Provision of Health Care Services

The BOP provides health care services to inmates primarily through in‑house medical providers employed by the BOP or assigned to the BOP from the Public Health Service (PHS) and contracted medical providers who supply either comprehensive or individual medical services.

In-house Medical Providers

The HSUs at each of the BOP's 114 institutions provide routine, ambulatory medical care. These units provide care for patients with moderate and severe illnesses, including hypertension and diabetes, as well as care for patients with serious medical conditions, such as Human Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Syndrome (AIDS). HSU outpatient clinics provide diagnostic and other medical support services for inmates needing urgent and ambulatory care. The HSUs are equipped with examination and treatment rooms, radiology and laboratory areas, dental clinics, pharmacies, administrative offices, and waiting areas. The HSUs are staffed by a combination of BOP health care employees and PHS personnel consisting of physicians, dentists, physician assistants, mid-level practitioners, nurse practitioners, nurses, pharmacists, psychiatrists, laboratory technicians, x-ray technicians, and administrative personnel. At each institution, the Clinical Director directs the clinical care of inmates and supervises the BOP and PHS health care staff.

As part of its internal health care network, the BOP operates several medical referral centers (MRC) that provide advanced care for inmates with chronic or acute medical conditions. The MRCs provide hospital and other specialized services to inmates, including full diagnostic and therapeutic services and inpatient specialty consultative services. Inpatient services are available only at MRCs. BOP medical personnel refer inmates to the MRCs or an outside community care provider when the inmates have health problems beyond the capability of the HSU.

Contracted Medical Providers

When the BOP's internal resources cannot fully meet inmates' health care needs, the BOP awards comprehensive and individual contracts to supplement its in-house medical services. Comprehensive contracts provide a wide range of services and providers, while individual contracts usually provide specific specialty services.

The comprehensive contracts and individual contracts exceeding $100,000 are awarded by the BOP’s Field Acquisition Office in Grand Prairie, Texas. The individual contracts not exceeding $100,000 are awarded by each institution’s contracting personnel.

According to data provided to the OIG by officials at the 114 BOP institutions, as of May 2007 these institutions had 108 comprehensive services contracts or blanket purchase agreements and 343 individual services contracts. From the beginning of the contracts through May 2007, BOP officials reported total expenditures of more than $249 million related to these 451 contracts and agreements.11

Necessary Medical Care

According to BOP Program Statement P6010.02 Health Services Administration, the BOP is responsible for delivering health care to inmates in accordance with proven standards of care without compromising public safety concerns. The BOP’s Patient Care policy delineates the following five categories of health care services provided to inmates. In this audit, we could not associate how much of the BOP’s medical obligations related to each of these categories because the BOP does not segregate medical cost data by these categories.

BOP Policy Guidance

The BOP provides policy and guidance to BOP institutions primarily in the form of program statements. As of October 2007, the BOP had 20 program statements related to the management and administration of health care. Appendix VI contains a summary of these program statements. In addition to the program statements, the BOP has established the following 16 clinical practice guidelines describing specific medical, dental, and mental health services that BOP management expects to be provided to inmates.

The Preventive Health Care guideline contains procedures that BOP management officials expect to be provided to all inmates. The other 15 guidelines address a particular health condition and contain procedures specific to servicing that condition. The Preventive Health Care guideline, which was updated in April 2007, contains the preventive health and diagnostic procedures found in 9 of the other 15 guidelines, but it does not contain the specific procedures related to treatment of the health conditions covered by the other guidelines. The Preventive Health Care guidelines also do not contain the preventive health procedures from four guidelines that are not considered chronic care (MRSA Infections, Headaches, Varicella Zoster Virus Infections, and Detoxification of Chemically Dependent Inmates); and two guidelines that are considered chronic care (Asthma and Gastroesophageal Reflux Disease Dyspepsia and Peptic Ulcer Disease).

For this audit, we focused on the procedures in the BOP’s Preventive Health Care guideline because:

Prior Audits, Inspections, and Reviews

Several previous audits, inspections, and reviews by the Department of Justice (DOJ) Office of the Inspector General (OIG) and the Government Accountability Office (GAO) have reported on the provision of health care by the BOP. These audits, inspections, and reviews are briefly summarized below.

Office of the Inspector General Reports

Individual Audits of BOP Contracts for Medical Services

From August 2004 through March 2007, the OIG issued nine audit reports on BOP contracts for medical services. The OIG identified major internal control deficiencies for eight of the nine medical services contract audits. The deficiencies included weaknesses in procedures or processes for calculating discounts, reviewing and verifying invoices and billings, paying bills, and managing the overall administration of the contracts. Finding 2 and Appendix X of this report contain more details about the results of these audits.

Audit of BOP Pharmacy Services

In a November 2005 report on pharmacy services within the BOP, the OIG reported on the BOP’s efforts to: (1) reduce increasing costs of its prescription medications; (2) ensure adequate controls and safeguards over prescription medications; and (3) ensure its pharmacies complied with applicable laws, regulations, policies, and procedures.13 The OIG found numerous deficiencies, including the:

The OIG made 13 recommendations for improving the administration of the BOP’s pharmacy services. The recommendations sought to ensure that:

The BOP agreed with the audit recommendations. The BOP implemented corrective action for each recommendation and the OIG closed the audit report based on the BOP’s corrective actions.

Inspection of Inmate Health Care Costs in the BOP

In November 1996, the OIG reported on factors contributing to inmates' health care costs and the BOP's initiatives to contain these costs.14 The OIG also reported on the BOP's corrective actions in response to the Department of Justice's FY 1992 Management Control Report.15 The OIG found the following.

The OIG recommended that the BOP:

The BOP generally agreed with the recommendations. The BOP also took corrective action on each recommendation and the OIG closed the inspection report based on the BOP’s corrective actions.

Government Accountability Office Reports

GAO Testimony Regarding BOP Medical Cost Containment

In April 2000, GAO staff testified to Congress that the BOP had initiated cost containment efforts such as restructuring medical staffing, obtaining discounts through bulk purchases, leveraging resources through cooperative efforts with other governmental entities, and privatizing medical services. The BOP also had placed tele-medicine in eight facilities and planned to equip all the BOP facilities during FY 2000.16

The GAO staff also testified that planned cost-saving measures required legislative action. These measures consisted of a $2 fee for each health care visit requested by a prisoner (as a deterrent to unnecessary visits), and a Medicare-based cap on payments to community hospitals that treat inmates.17 The GAO recommended that the BOP negotiate more cost-effective contracts with community hospitals that could require bidders to propose a “Medicare federal rate” adjusted by markups or discounts, which was expected to simplify the comparison of prices under consideration.18

Report on Inmates Access to Health Care

In a February 1994 report, the GAO reported on the adequacy of the BOP’s medical services and the effectiveness of its medical service’s quality assurance program.19 The GAO reviewed care for inmates with special medical needs, the BOP’s quality assurance systems, qualification of BOP physicians and of other health care providers used by the BOP, and the BOP’s consideration of cost effective alternatives to meet rising needs for medical services. The GAO found the following.

The GAO recommended that the BOP:

While the BOP did not agree with the GAO’s conclusion regarding the medical care it is able to provide to inmates in the facilities GAO visited, the BOP agreed with the GAO’s specific findings. The BOP agreed to take corrective action on first two recommendations. However, the BOP believed that the intent of the GAO’s remaining two recommendations was being dealt with through existing systems and plans. The GAO did not fully agree with the BOP’s position on the last two objectives and indicated in the report that the BOP still needed to take additional actions on these issues.

OIG Audit Objectives and Approach

The OIG initiated this audit to determine whether the BOP: (1) appropriately contained health care costs in the provision of necessary medical, dental, and mental health care services; (2) effectively administered its medical services contracts; and (3) effectively monitored its medical services providers.

We performed audit work at BOP headquarters and at the following BOP institutions: the USP Atlanta (Georgia), USP Lee (Virginia), FMC Carswell (Texas), FCC Terra Haute (Indiana), and FCC Victorville (California). In addition, we surveyed the 88 BOP locations where we did not perform on-site work. The details of our testing methodologies are presented in the audit objectives, scope, and methodology contained in Appendix I.

This audit report contains 3 finding sections. The first finding discusses the BOP’s efforts to contain the growth of health care costs and to deliver necessary health care to inmates. The second finding discusses the BOP’s administration of medical services contracts. The third finding discusses the BOP’s efforts to monitor its medical services providers, both in-house and contract staff.

  1. This audit focused on the medical care provided to only those inmates housed in Bureau of Prison (BOP) facilities.

  2. Estelle v. Gamble, 429 U.S. 97, 97 S. Ct. 285, 50 L. Ed. 2d 251 (1976).

  3. “Your Right to Adequate Medical Care,” in A Jailhouse Lawyer’s Manual (New York: Columbia University, School of Law, Chapter 18, page 494, which cited the following reference: Estelle v. Gamble, 429 U.S. 97, 104, 97 S. Ct. 285, 291, 50 L. Ed. 2d 251, 260 (1976) (citing Gregg v. Georgia, 428 U.S. 153, 173, 97 S. Ct. 2909, 2925, 49 L. Ed. 2d 859, 874 (1976)).

  4. The length of the BOP’s medical contracts varied, but most of the contracts included a base year and 4 option years. Accordingly, the expenditures related to the 451 active contracts and agreements covered the time each contract began through May 2007.

  5. Every BOP institution is required to have a Utilization Review Committee, chaired by the institution’s Clinical Director, that reviews various aspects of inmate health care, such as the need for outside medical, surgical, and dental procedures; requests for specialist evaluations and treatments with limited medical value; and considerations for extraordinary care.

  6. Department of Justice, Office of the Inspector General, The Federal Bureau of Prisons Pharmacy Services, Audit Report Number 06-03 (November 2005).

  7. Department of Justice, Office of the Inspector General, Inmate Health Care Costs in the Bureau of Prisons, Inspections Report Number I-97-01 (November 1996).

  8. The Federal Managers Financial Integrity Act of 1982 (Act) required the head of each executive agency to prepare a statement indicating that the agency’s systems of internal accounting and administrative control either fully or do not fully comply with the requirements of the Act. If the control systems do not fully comply with the Act, the agency head is required to include a report, called a Management Control Report, identifying any material weaknesses in the agency's systems of internal accounting and administrative control and the plans and schedule for correcting the weakness.

  9. Tele-medicine is a method of providing health care from a remote location using technology such as video conferencing modified to include peripheral devices that produce images of diagnostic quality.

  10. The BOP implemented the $2 fee for inmate health care visits as discussed in more detail on page 20 of this report.

  11. The “Medicare federal rate” is a common or standard benchmark rate for specific medical services identified in Medicare diagnosis-related groups.

  12. U.S. General Accounting Office, BUREAU OF PRISONS HEALTH CARE, Inmates’ Access to Health Care Is Limited by Lack of Clinical Staff, GAO/HEHS-94-36 (February 1994), 1.

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