The primary mission of the United States Marshals Service (USMS) is to protect the federal courts and ensure the effective operation of the judicial system. Integral to that mission is the transporting, housing, and guarding of federal prisoners during the trial process. The USMS is responsible for housing and maintaining an average daily population of about 40,000 federal prisoners awaiting trial in federal courts.

Federal prisoners in USMS custody are housed in local jails, contract facilities, and federal Bureau of Prisons (BOP) facilities throughout the country. Depending upon the length of a prisoner's court trial, time spent in USMS custody may run from several days to several years, during which time the USMS is responsible for the well-being of that individual, including providing for adequate medical care.

In-House Medical Care

For basic medical screening and routine medical services for federal prisoners, the USMS relies largely on local and contract jails, as well as the BOP, most of which are equipped with in-house medical clinics within their facilities. The costs of such in-house medical services are usually covered in the per diem rates charged to the USMS under the terms of an Intergovernmental Service Agreement (IGA),⁵ in the case of a local jail, or the contracted jail day rate, in the case of a private contract facility. Services provided in BOP facilities are done so at no cost to the USMS.

In-house medical services provided by the jails housing federal prisoners can vary substantially. Some local jails may have sophisticated medical facilities, replete with X-ray and dialysis machines, Tuberculosis (TB) isolation cells, and dental services. Some facilities may even be able to accommodate minor surgical procedures. At the other end of the spectrum are facilities with very limited health care services. Prisoners at these facilities must often be transported outside for procedures that are routinely performed at jails with more comprehensive medical services.

To assess the quality of care provided federal prisoners at local jails, the USMS has a jail inspection program. Current USMS jail inspection guidelines include standards established by the American Correctional Association (ACA).⁶ USMS deputy marshals, as a collateral duty, conduct these jail inspections and submit the reports to their district office. The reports rate the jails compliance with ACA standards and list any medical care deficiencies noted at the jail.

USMS officials stated that only a small percentage of local jail facilities met the standards required of the ACA for accreditation. Indeed, some facilities have been subject to prisoner or third-party litigation because of substandard conditions of confinement. Because of the limited number of ACA-accredited jails available to house federal prisoners, USMS district officials are not precluded from using non-accredited jails when warranted by the need for bed space, as long as 24-hour access to emergency medical services is be available.

Outside Medical Care

When a prisoner in USMS custody requires advanced or specialized medical care, the prisoner is usually sent out to a local health care facility. In contrast to in-house medical care, USMS district offices are directly involved in the process of acquiring outside medical care. USMS district offices have the discretion, upon recommendation of a competent medical authority, to acquire and provide reasonable and necessary outside medical services for federal prisoners. Discretion comes into play in situations involving non-emergency procedures. Given that most prisoners are in USMS custody for relatively short time periods, certain non-emergency procedures, while medically appropriate, may be delayed provided there are no health risks to the prisoner. In fiscal year (FY) 2002, the USMS spent approximately $43 million on outside medical services for its prisoners, which included $36 million for medical services and $7 million in related guard costs.

Depending on the nature of the illness or injury, the services provided may involve hospital stays of hours, days, weeks, and in some cases even months. The risks inherent in providing of outside medical care to prisoners are myriad and include the possibility of: 1) escape; 2) death or injury to an innocent bystander, law enforcement official, or the prisoner during an escape attempt; and 3) exposure of the general public to possibly contagious diseases.

Management of Prisoner Medical Care

The USMS Office of Interagency Medical Services (OIMS), a branch of the Prisoner Services Division, is responsible for providing overall policy direction and assistance to the field in all matters concerning prisoner medical services. Established in 1994, the OIMS has several functions, including: 1) case management for the districts;⁷ 2) establishing policies and procedures; 3) cost management efforts, such as the BOP/USMS medical consolidation program; ⁸ and 4) TB management.

Management of the day-to-day operations rests with the district offices. Specifically, USMS district office personnel must: 1) approve the medical treatment (sometimes in consultation with OIMS); 2) provide for transportation and guard services for the prisoner; 3) document the procedure(s) and cost; 4) enter medical billings into the Financial Management System (FMS); and 5) ensure that transactions are properly recorded and payments to medical providers are timely paid.

Prior Reports

The Department of Justice (DOJ) Justice Management Division previously reviewed USMS medical services in its 1998 Detention and Incarceration Study, as well as in its Review of the USMS Prisoner Medical Services issued December 1994. The review and subsequent study highlighted areas of concern and opportunities for improvement including:

• Personnel involved in transporting and guarding prisoners in buses, vans, and Justice Prisoner Alien Transportation System (JPATS) flights may be at risk of exposure to TB and other infectious diseases.

• The BOP and the USMS need to coordinate agreements with hospitals and other health care providers to achieve the best possible rates and reduce duplication. The BOP has since made all its national hospital contracts inclusive of all federal prisoners, thus allowing the USMS to piggyback on these contracts, but the USMS does not always use these contracts.

• The USMS should incorporate medical care and related services into its IGAs and contracts. Further, the USMS should renegotiate IGAs that are incurring high costs for outside medical services.

• USMS districts should utilize to the fullest extent possible local jails with the broadest range of in-house medical capabilities in order to reduce the need for costly outside referrals.

• The USMS should utilize hospitals with locked wards to reduce guard costs associated with outside care.

• The USMS through its Cooperative Agreement and Excess Property Programs should assist local jails in developing and expanding in-house medical capabilities to reduce the need for outside medical care for federal prisoners.

• The USMS should work with the Immigration and Naturalization Service (INS) (since transferred to the Department of Homeland Security) and BOP to determine the feasibility of negotiating single contracts for medical and guard services to meet the needs of all three agencies.

• The USMS should examine the feasibility and requirements of contracting out prisoner medical care.

• USMS districts should be alerted about what signs and symptoms to look for and precautions to take relative to potential contagious diseases.

• The USMS should make every effort to provide at least 48 hours notice of planned moves and to obtain medical records and medications prior to transporting a sick prisoner.

• The USMS should reexamine its booking forms and procedures to ensure that they adequately cover prisoner health status.

In addition, Booz-Allen & Hamilton, Inc., in a Streamlining Review issued July 2002, recommended that the USMS contract for a managed care health system to streamline prisoner medical care.⁹ The report stated that the USMS managed care system should provide for the following:

• Negotiated contracts with medical facilities and providers, claims processing and payment, utilization review and quality management that enables USMS districts to arrange for appropriate prisoner health care at substantial savings to the taxpayer.

• A managed care network with community physicians, hospitals, ancillary service support systems, and other ancillary services to support each site where USMS prisoners require outside medical care and are housed in a major-use detention facility.

• An automated centralized medical claims system to process and re-price valid claims for medical care and supporting medical services provided to USMS prisoners.

• Development of a preferred provider network, administration, referral management, denial of care, claims processing and payment management. The contract should also include a utilization and quality management program, referral management and discharge planning.

5. The Intergovernmental Agreement states that a negotiated daily rate per prisoner will be paid by the USMS to the jail.
6. The ACA is a professional membership organization dedicated to the improvement of corrections and the development and training of correctional professionals. The ACA's membership consists of individuals and organizations involved in all facets of corrections, including adult institutions and jails, community corrections, juvenile justice, institutions of higher learning, and probation and parole.
7. The OIMS, in cooperation with the Public Health Service, provides advice to the district offices when a prisoner requires extensive medical treatment, or the district office is unsure of whether specific services are allowable under USMS policy.
8. In 1993, the USMS and BOP signed a Memorandum of Understanding citing the need for the two agencies to work together to contain health care costs. Toward that end the agencies have developed pilot projects at select institutions that house USMS prisoners. The pilot projects have focused on reducing health care costs through sharing arrangements, joint contracts, and other methods designed to contain medical costs.
9. The USMS has been pursuing this initiative.