Inspections Report

In fiscal year (FY) 1992 the Department of Justice's (DOJ) Management Control Report regarding the Bureau of Prisons (BOP) identified the rising costs of health care for inmates as a significant concern. In April 1993 the BOP identified six corrective actions and target dates for implementation.

The BOP continues to strive for a balance between cost and quality of care and believes that quality of care itself is a cost preventive strategy. Specifically, the 6 corrective actions to the Management Control Report and 4 of the 20 objectives in the BOP's long-term strategic plan's Inmate Programs and Services goal demonstrate the BOP's commitment to control inmate health care costs. The six corrective actions involve long-term preventive efforts and in some cases voluntary inmate participation. From these corrective actions, the BOP anticipates a reduction in inmate medical costs in the long-term.

The BOP has developed procedures to track the implementation of the initiatives in the strategic plan at the local, regional, and Central Office levels. Most of the corrective actions are incorporated into the BOP's strategic plan initiatives. Institutions and regions submit quarterly reports on strategic plan activities. By reviewing the quarterly report, management officials can determine whether programs are being implemented at the institutional and regional levels.

The BOP reported that it has completed implementation of five of the six corrective actions identified in April 1993. The BOP believes it will complete the sixth corrective action by its September 30, 1997, target date.

Listed below are the six corrective actions and some specific initiatives taken by the BOP to address each corrective action.

In FY 1989 the BOP institutions with male inmates were offering a daily diet of 5,400 calories, of which 2,376 calories were obtained from fat. The daily menu also contained 847 milligrams (mg) of cholesterol and 10,000 mg of sodium.

The Health Services Division's (HSD) FY 1995 goal for male and female inmates was a daily diet of 3,500 and 2,700 calories, respectively. The men's diet goal included less than 30 percent of calories from fat, 300 mg of cholesterol, and 4,000 mg of sodium. In FY 1995 the BOP institutions with male inmates offered a daily diet of 3,367 calories with 32.5 percent of calories obtained from fat, 433 mg of cholesterol, and 6,520 mg of sodium. The target of 30 percent or less of calories from fat is consistent with established recommendations in Healthy People 2000. [ Healthy People 2000: National Health Promotion and Disease Prevention Objectives , U.S. Department of Health and Human Services and the Public Health Service.]

Since FY 1989 the BOP has reduced male inmates' daily menu by 2,033 calories and the number of calories from fat by 1,282. Within these menus, the BOP also reduced cholesterol by 414 mg and sodium by 3,480 mg. In FY 1996 the BOP plans to develop training materials to educate its Food Administrators on how to offer healthier menu alternatives.

At each institution visited, we toured the staff and inmate dining halls and confirmed that menus were displayed, nutritional cards were visible on the serving counters, and health and nutrition pamphlets were available for staff and inmates.

The BOP reported that it completed this corrective action on September 30, 1993.

The BOP has several initiatives that will improve the efficiency of medical transportation.

The BOP reported that it completed this corrective action on September 30, 1995.

On February 22, 1994, the HSD issued Program Statement 6100.01, Health Promotion and Disease Prevention (HPDP) for Inmates. The program statement provides inmates with opportunities to develop and maintain positive, voluntary lifestyle changes. The HPDP program goals are to reduce the chances of inmates developing preventable diseases through education and behavior modification and to educate inmates with diseases on how to manage the diseases effectively. This program corresponds with Healthy People 2000.

The institutions we visited had established HPDP programs. Each institution offered a variety of educational opportunities for the inmates including blood pressure and cholesterol screening and seminars on specific health topics. For example, Federal Medical Center (FMC) Fort Worth's program focused on a particular topic each month: February as American Heart Month, March as National Nutrition and Acquired Immune Deficiency Syndrome (AIDS) Awareness Month, May as National High Blood Pressure Education and National Physical Fitness and Sports Month, September as National Cholesterol Education Month, October as Family Health Month, and November as Great American Smokeout and National Diabetes Month.

On June 13, 1995, the BOP issued Change Notice CN-07 to Program Statement 4500.03, Trust Fund Management. This change notice provided guidelines for the sale of approximately 30 over-the-counter medications [ Over-the-counter medications include non-prescription drugs, home remedies, and patent medicines.] from the commissary. The HSD Chief Pharmacist told us that he believed the sale of over-the-counter medications would reduce the number of inmates reporting for institutional sick call. Furthermore, he stated that the BOP had realized significant savings by providing over-the-counter items. Each institution we visited was either selling over-the-counter medications in the commissary or had requested authority to sell medications in the commissary.

The BOP reported that it completed this corrective action on September 30, 1995.

The BOP's Program Statement 6000.04 establishes requirements to implement Health Services Quality Assessment and Improvement Programs (QA&IP) at all institutions with independent ambulatory care services. The QA&IP includes peer reviews, mortality reviews, professional credential reviews, focus reviews, risk management reviews, and patient satisfaction surveys. Each institution we visited had established a QA&IP. In addition, those institutions' QA&IP personnel had issued reports on the completed reviews and established follow-up systems on the recommendations and the corrective actions.

The BOP completed development of a quality assessment and improvement program and reported the corrective action completed on September 30, 1995. As of FY 1995, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) had accredited 45 BOP institutions. In FY 1996 the BOP planned for JCAHO to inspect an additional 26 institutions.

The BOP's Operations Memorandum of June 15, 1995, notified institutions that it exercised option years for the Prime Vendor (PV) contracts for pharmaceutical drugs and products. Since 1993 the BOP has administered PV contracts through the Department of Veterans Affairs. Within each BOP region, there is a contractor who is the prime vendor for that region. The prime vendor system allows the BOP to place orders directly into an on-line computer system, which is provided by the contractor. The contractor guarantees next day delivery.

As discussed earlier in the report, 97 percent of the BOP's institutions had initiated community provider contracts as of FY 1995. In addition, the BOP has entered into an agreement with the Department of Defense to provide medical consultant services through telemedicine. The telemedicine program will involve the Veterans Administration Hospital in Lexington, Kentucky; the United States Penitentiaries Lewisburg and Allenwood located in Pennsylvania; and the FMC at Lexington, Kentucky.

The BOP's Medical Director is quoted in Corrections Alert that he believes telemedicine will become a very important part of the correctional health care system within the next five years. He does not believe that it will replace the human resource element but will become an adjunct to the correctional health care system by increasing security, providing better access to quality care, and reducing health care costs. [ Sarah E. Mooney and Bruce Mendelsohn, "TX Conducts Health Care by Head Count," Corrections Alert , September 5, 1995, pp. 4-5.]

The BOP reported that it completed this corrective action on September 30, 1995.

We found that the BOP uses pre-sentencing information pertaining to an inmate's medical condition as well as information obtained from an inmate's physical examination at the institution to designate inmates with special needs to an appropriate institution. Furthermore, the BOP ensures that it properly records all the medical conditions of inmates so the BOP staff can better treat the inmates. These procedures assist the BOP in placing inmates in institutions that can most appropriately provide the type of care needed.

According to HSD's Long-Range Medical Facilities Plan, September 6, 1995, in FY 1995 the BOP had 2,196 medical, mental health, and chronic beds: 138 at Federal Correctional Institution (FCI) Butner, North Carolina; 302 at FMC Carswell, Fort Worth, Texas; 460 at FMC Fort Worth, Texas; 386 at FMC Lexington, Kentucky; 363 at FMC Rochester, Minnesota; and 547 at United States Medical Center for Federal Prisoners (USMCFP) Springfield, Missouri. Medical beds may be categorized as either medical or mental health and acute or chronic care. Over the next 10 years, BOP plans to increase its total health care capacity to approximately 3,000 beds.

The HSD's Managed Care Certifying Officer/Medical Designator (Medical Designator) provided information on inmate waiting lists for BOP's six medical centers. As of September 27, 1995, 37 inmates were awaiting available beds. Of these 37 inmates, 15 inmates required regular beds, 20 inmates required orthopedic beds, and 2 inmates with AIDS required intensive care beds. We found that 24 of the 37 inmates awaiting beds were at USMCFP Springfield, 18 for orthopedic beds and 6 for regular beds. According to the HSD Medical Designator, USMCFP Springfield had begun to designate low security inmates awaiting orthopedic beds to FMC Fort Worth. The inmate who had been on the waiting list the longest was a dialysis patient at USMCFP Springfield awaiting transfer to FMC Lexington since April 1995.

The target completion date for this corrective action is September 30, 1997. We believe that the BOP is working toward meeting this target date.

TARGET DATE	DATE COMPLETED	CORRECTIVE ACTIONS
9/30/93	9/30/93	Continue further development and implementation of a sound nutritional program through the expansion of heart healthy choices on inmate menus and education of staff and inmates.
9/30/93	9/30/95	Improve the efficiency of medical transportation by reducing holdover points when transporting inmates for medical purposes, reducing time between discharge and availability of transport from medical referral centers, pursuing a national air transportation contract, and exploring military sharing agreements.
9/30/95	9/30/95	Reinforce the concept of health promotion and disease prevention throughout the BOP by developing a philosophy in conjunction with the Healthy People 2000, coordinating this philosophy with other disciplines, developing and implementing health education for inmates and staff, and implementing selected over-the-counter medication sales in the commissary.
9/30/95	9/30/95	Continue to improve the quality of health care through a uniform quality management program.
9/30/95	9/30/95	Manage costs of health care through initiatives such as pharmaceutical prime vendor, negotiated contracts, inmates' utilization and sharing agreement with governmental entities.
9/30/97	pending	Ensure inmates are designated to institutions commensurate with their medical needs and institutional capability by implementing an institutional medical stratification program, assisting the Mid-Atlantic Region with inmate medical classification pilot programs, and ensuring appropriate consultant availability for inmates within the local community.

Public Health Service (PHS) Associated Costs	Salary and personnel benefit costs for the use of PHS officers in the Bureau of Prisons (BOP). Costs include relocation of PHS officers to BOP facilities.
Community Provider Services	Obligations charged for outside medical services, including community hospital services, physician assistance inside and outside an institution, and laboratory services.
Guard Escort Service	Costs for contract guard service and BOP employees' guard escort overtime.
Salaries	Salary and personnel benefit costs for full-time and part-time BOP employees.
Consultants	Obligations for all contractual and non-contractual services. For example, institutions contract with specialty physicians for in-house services.
Equipment	Obligations for replacement equipment. This does not include equipment costs for new or renovated medical facilities.
Supplies	Obligations for all supply purchases, including such items as bandages, pharmaceutics, reference texts, office supplies, protective gloves, and hepatitis vaccines and testing.
Human Immunodeficiency Virus (HIV) Testing	Obligations related to HIV testing.
Airlift Expenses	Obligations related to medical airlifts, including overtime, transportation, and travel related to transferring inmates from one facility to another.
Headquarters Expenses	Obligations charged to the Health Services Division at the Central Office level.
Other Costs	Miscellaneous obligations such as transportation, travel, printing, and interest.

ITEM	EXPLANATION
Medical Care Services	Professional and hospital services and health insurance imputation.
Professional Medical Services	Physicians, dentists, eye care providers, and other medical professionals.
Physicians' Services	Includes all services by medical physicians in private practice, including osteopaths, that are billed by the physician. Includes house, office, clinic, and hospital visits (excludes ophthalmologists).
Dental Services	Includes dental services performed by dentists, oral or maxillofacial surgeons, orthodontists, periodontists, or other dental specialists in group or individual practice. Treatment can be provided in the office or a hospital.
Eye Care	Includes services provided by opticians, optometrists, and ophthalmologists. Includes dispensing of eye glasses and contact lenses.
Services by Other Medical Professionals	Includes services performed by other professionals such as psychologists, chiropractors, therapists, podiatrists, and nurse practitioners in or out of the office.
Hospital and Related Medical Services	Includes hospital room and board, inpatient services, outpatient services, emergency room services, and nursing home care.
Hospital Room	Room and board for any type of hospital room, such as private, intensive care, routine nursery, or ward that is billed by the hospital.
Other Inpatient Services	Hospital services for inpatients, such as pharmacy, laboratory tests, radiology services, and operating room charges that are billed by the hospital. Also includes nursing home care.
Outpatient Services	Hospital services for outpatients such as laboratory tests, short stay units, radiology, physical therapy, and emergency room visits.

BOP HEALTH SERVICES POSITIONS AS OF MAY 20, 1996
CATEGORY	TOTALS	PHS	BOP EMPLOYEES	VACANCIES
Administrative	83	17	63	3
Assistant Health Services Administrator	92	18	65	9
Attorney	1	0	1	0
Associate Warden	4	1	3	0
Computer Specialist	2	0	2	0
Dental Assistant	35	0	32	3
Dental Hygienist	20	8	9	3
Dental Technician	13	0	13	0
Dentist	155	136	8	11
Dietician	4	1	3	0
Emergency Medical Technician/Paramedic	18	0	13	5
Health System Intern	7	0	4	3
Health Educator	6	0	6	0
Hospital Housekeeping	3	0	3	0
Health Services Administrator	87	9	76	2
Infectious Control	7	0	6	1
Laboratory Technician	114	4	99	11
Medical Doctor	257	12	202	43
Medical Records Technician	203	9	179	15
Medical Clerk	37	0	34	3
Mid-Level Practitioner	88			88
Nurse Practitioner	14	11	3	0
Physician Assistant (PA)	111	5	106	0
PA - Certified	68	10	58	0
Unlicensed Medical Graduate	439	0	439	0
Nurses
Registered Nurse	408	111	251	46
Licensed Practical Nurse	95	0	84	11
Clinical Nurse Assistant	7	0	5	2
Pharmacist	117	90	23	4
Pharmacy Technician	14	0	14	0
Psychologist	12	2	9	1
Quality Control	17	3	13	1
Rehabilitative	37	12	18	7
Secretary	84	0	78	6
Commissioned Officer Student Training and Extern Program	11	11	0	0
Social Work	18	7	10	1
Supply	11	0	10	1
Unit Staff	14	0	13	1
TOTALS	2,713	477	1,955	281

The scope of the inspection included inmate health care costs from October 1, 1989, to September 30, 1994, and earlier periods as needed. We reviewed Health Services Division planning and budgeting documents, financial reports, selected medical contracts, payment vouchers, contractor invoices, inmate medical records, and institutional correspondence.

We visited five Bureau of Prison facilities: the United States Penitentiary at Lewisburg, Pennsylvania; the Federal Correctional Institutions at Allenwood, Pennsylvania and Seagoville, Texas; the Low Security Correctional Institution at Allenwood, Pennsylvania; and the Federal Medical Center at Fort Worth, Texas. We used the Bureau of Prison's Financial Management Information System to select our sample of institutional records and site visit locations.

On September 11, 1996, the Inspections Division sent a copy of the draft report to the Bureau of Prisons (BOP). Our analysis of the response from the BOP follows.

1. Recommendation 1 - Resolved-Closed. On October 8, 1996, a Senior Deputy Assistant Director for the Health Services Division provided a memorandum that outlined additional action taken by the BOP. In fiscal year 1996, the BOP transferred the funds for outside guard service from the Central Office budget to the regions; the regions distributed the funds and the authority and responsibility for the funds to the institutions. In the past, institutions could charge their outside guard service costs to the Central Office fund.

Because the Wardens are now responsible for institutional management of their outside guard service funds, the BOP anticipates a reduction in these costs. The BOP based its expectations for savings from this action on a pilot study conducted in the North Central Region. The pilot study resulted in significant savings on the transfer of outside guard service funds to the institution.

We agree with the Senior Deputy Assistant Director's statement that the BOP should not dictate the guard service that Wardens use. However, the Central Office and regions should monitor the effects and cost savings resulting from the transfer of these funds to the Wardens.

Based on the additional information supplied, we agree with the corrective action taken. We require no further response.

2. Recommendation 2 - Resolved-Closed. We agree with the corrective action taken. We require no further response.

3. Recommendation 3 - Resolved-Closed. We agree with the corrective action taken. We require no further response.