November 1996

Report Number I-97-01








BOP's Health Care Mission and Services

Inmate Health Care Costs

Factors Contributing to Inmates' Health Care Costs

BOP's Medical Cost Containment Efforts

BOP's Monitoring of Inmate Health Care Costs


Community Provider Services

Additional Managed Care Initiatives

Medical Guard Escort Service


Staffing of Mid-level Practitioner, Nurse, and Emergency Medical Technician/Paramedic Positions


Inmate Fees for BOP Health Care

Implementation Considerations

Feasibility of a Co-Payment System

Anticipated Benefits of a Co-Payment System


APPENDIX I - Status of the Management Control Report Corrective Actions

APPENDIX II - Definitions of Health Care Cost Categories

APPENDIX III - Medical Care Services Indexes

APPENDIX IV - BOP Health Services Positions

APPENDIX V - Scope and Methodology

APPENDIX VI - Abbreviations

APPENDIX VII - Bureau of Prison's Response to the Draft Report - NOT INCLUDED IN THIS HYPERTEXT VERSION.

APPENDIX VIII - Office of the Inspector General's Analysis of Management's Response






The Bureau of Prisons (BOP) is required by Federal regulations to provide suitable medical care to all inmates in its custody. Under the supervision of the Medical Director, the Health Services Division (HSD) provides overall direction for the BOP's inmate health care program, using Public Health Service officers and BOP health care practitioners to deliver inmate health care.

The rising costs of inmate health care have been a significant concern to the BOP as it furnishes medical, dental, and mental health services that are consistent with acceptable community standards. Between fiscal years (FY) 1990 and 1994, inmate health care costs increased by $124.8 million, or 91 percent. In this inspection, we examined factors contributing to inmates' health care costs, the BOP's initiatives to contain these costs, and the BOP's corrective actions to the Department of Justice's Management Control Report.

The BOP attributed most of the increase in inmate health care costs to several factors beyond its control: namely, a growing inmate population, the general aging of the inmate population, inflation in the medical services industry, and an increase in the number of inmates with drug-related conditions. The BOP also identified two other factors that contributed to increased expenditures: the growth in the number of incoming inmates needing immediate medical treatment, which frequently resulted in referrals to community care providers, and the implementation of medical community treatment standards.

The BOP has implemented numerous inmate health care cost containment initiatives to combat rising costs and to meet the health care demands of a growing inmate population. The BOP's Long-term Strategic Goals for 1996...and Beyond contain four specific objectives that directly relate to inmate health care cost containment: (1) health promotion and disease prevention; (2) quality assessment and improvement; (3) managed care initiatives; and (4) special program needs of physical disabilities, chronic and terminal illnesses, and geriatric offenders.

We found that, overall, the BOP's initiatives kept per capita costs from rising significantly. The BOP's average health care cost per inmate increased by 27 percent between FYs 1990 and 1994, which is less than the rise in the consumer price index for medical care during the same period. However, our review disclosed that some health care cost categories--community provider services, medical guard escort service, and salaries--have continued to increase in spite of the BOP's containment efforts. We believe the BOP could take additional actions to control some costs.

Community Provider Services - The BOP purchases health services from community care providers to supplement its direct health care delivery system. In 1990 the BOP implemented a community provider services contract initiative to reduce costs. We found that 97 percent of the BOP institutions have community care provider contracts affording them discounted rates for services. As a result of the initiative, the BOP has limited the increase in total community provider services costs. However, we found that, on a per capita basis, community provider services costs still increased at a higher rate than the consumer price index for medical care. We believe the BOP could further enhance its efforts to control costs by identifying data to measure community provider services activities and review the data for patterns and trends.

Medical Guard Escort Service - When inmates require medical treatment outside an institution, the inmates are escorted by BOP correctional staff to the medical facility and guarded at the community medical facility by either BOP correctional staff or contract guards. Although some minimum and low security level institutions use contract guards for inmates' medical visits, we believe a much greater number of institutions could use contract guards. Thus, overtime expenditures for BOP employees in an off-duty status who serve as medical guards would be reduced. Wardens must take a more active role in acquiring guard service contracts and make the ultimate determination for the use of contract guards.

Staffing of Mid-level Practitioner and Nurse Positions - We found that mid-level practitioners comprised 27 percent of the BOP's health service positions and that nurses comprised 19 percent. We recommend that Wardens assess their current staffing mix of mid-level practitioners and nurses in an effort to use lower graded positions whenever possible without reducing the level of inmate care. If an institution utilized a greater percentage of nurses rather than mid-level practitioners, the BOP would reduce salary expenditures.

In addition to these recommended cost containment actions, we believe the BOP could effectively implement an inmate co-payment fee for health care services and could anticipate the following benefits: (1) a decrease in the number of inmates attending sick call, (2) an increase in inmate accountability and responsibility for their own health care, and (3) an awareness by the public of inmates' financial participation in the cost of medical services received during incarceration. If the BOP receives statutory authority to collect a medical co-payment fee from inmates, the amount of revenue would be affected by the availability of inmates' financial resources and ongoing administrative costs.