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.
Source: OIG mapping of BOP facilities based on data provided by the BOP
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.
Director of BOP: The Director has overall authority to provide for the care and treatment of persons within the BOP’s custody. The Director has delegated this authority to the Assistant Director, Health Services Division (HSD).
Assistant Director, HSD: The Assistant Director, HSD, is responsible for directing and administering all activities related to the physical and psychiatric care of inmates. The Assistant Director has delegated this authority as it pertains to clinical direction and administration to the BOP Medical Director.
Medical Director: The Medical Director is the final health care authority for all clinical issues and is responsible for all health care delivered by BOP health care practitioners.
Regional Health Services Administrators: The Regional Health Services Administrators in the BOP’s six regional offices are responsible for responding to health care problems at all institutions within their region. The Administrators also advise the Regional Director and Deputy Regional Director in all matters related to health care delivery.
Institution Officials: The responsibility for the delivery of health care to inmates at the institution level is divided among various officials, staff, contractors, and others. Each institution has a Health Services Unit (HSU) responsible for delivering health care to inmates. The organization of the HSUs varies among institutions depending upon security levels and missions, but each HSU ordinarily has a Clinical Director and a Health Services Administrator who report to the Warden or Associate Warden. The Clinical Director is responsible for oversight of all clinical care provided at the institution. The Health Services Administrator implements and directs all administrative aspects of the HSU at the institution. Both the Clinical Director and the Health Services Administrator have responsibilities related to the supervision and direction of health services providers at the institution.
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.
Source: BOP Budget Execution Branch
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 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
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.
Medically Necessary – Acute or Emergent. Services in this category cover medical conditions that are of an immediate, acute, or emergent nature, which without care may be life threatening or would cause rapid deterioration of the inmate’s health or significant irreversible loss of function. Conditions in this category warrant immediate treatment that is essential to sustain life or function. Examples of conditions considered acute or emergent include, but are not limited to:
- myocardial infarction;
- severe trauma such as head injuries;
- precipitous labor or complications associated with pregnancy; and
- detached retina, sudden loss of vision.
Medically Necessary – Non-emergent. Services in this category cover medical conditions that are not immediately life-threatening, but without care the inmate has a significant risk of:
- serious deterioration leading to premature death;
- significant reduction in the possibility of repair later without present treatment; or
- significant pain or discomfort, which impairs the inmate’s participation in activities of daily living.
- chronic conditions (diabetes, heart disease, bipolar disorder, schizophrenia);
- infectious disorders in which treatment allows for a return to previous state of health or improved quality of life (HIV, tuberculosis); and cancer.
Medically Acceptable – Not Always Necessary. Services in this category cover medical conditions that are considered elective procedures that may improve the inmate’s quality of life. Examples in this category include, but are not limited to:
- joint replacement;
- reconstruction of the anterior cruciate ligament of the knee; and
- treatment of non-cancerous skin conditions, such as skin tags and lipomas.
- the risks and benefits of the treatment,
- available resources,
- natural history of the condition, and
- the effect of the intervention on inmate functioning in activities of daily living.
Limited Medical Value. Services in this category cover medical conditions for which treatment provides little or no medical value, are not likely to provide substantial long-term gain, or are expressly for the inmate’s convenience. Procedures in this category are usually excluded from the scope of services provided to BOP inmates. Examples in this category include, but are not limited to:
- minor conditions that are self-limiting,
- cosmetic procedures, or
- removal of non-cancerous skin lesions.
Extraordinary. Services in this category cover medical interventions that are deemed extraordinary because they affect the life of another individual, such as organ transplantation, or are considered investigational in nature.
Examples of conditions considered medically necessary – non‑emergent include but are not limited to:
These therapeutic interventions always require review by the institution’s Utilization Review Committee to determine whether the proposed treatment should be approved.12 The factors that should be considered in approving the proposed treatment include, but are not limited to:
Any treatment in this category that a health care provider recommends and the Clinical Director feels is appropriate requires review by the institution’s Utilization Review Committee.
Any treatment provided in this category requires the BOP Medical Director’s review and approval with notification to the Regional Director.
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.
Preventive Health Care
Management of Asthma
Management of Coronary Artery Disease
Management of Major Depressive Disorder
Detoxification of Chemically Dependent Inmate
Gastroesophageal Reflux Disease Dyspepsia and Peptic Ulcer Disease
Management of Headaches
Management of Human Immunodeficiency Virus (HIV)
Management of Lipid Disorders
HIV, Hepatitis-B, Hepatitis-C, Human Bites and Sexual Assaults
Management of Methicillin-Resistant Staphylococcus Aureus (MRSA) Infections
Management of Tuberculosis (TB)
Management of Varicella Zoster Virus Infections
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:
It addressed care for all inmates and not just inmates with specific illnesses;
It contained medical services that BOP management officials expected to be performed at all institutions; and
According to the BOP, health promotion and disease prevention is a primary objective of the BOP in its efforts to contain costs.
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:
BOP’s cost-benefit analysis of its prescription medication program contained errors and incorrect assumptions that could result in increased prescription medication costs rather than savings;
BOP needed to improve efforts to reduce prescription medication costs associated with waste;
BOP was not adequately accounting for and safeguarding prescription medications;
BOP lacked adequate internal controls for purchasing prescription medications, including ordering, receiving, and paying; and
BOP pharmacies did not always comply with applicable policies and procedures for dispensing and administering prescription medications.
The OIG made 13 recommendations for improving the administration of the BOP’s pharmacy services. The recommendations sought to ensure that:
a cost-benefit analysis is conducted for all cost savings initiatives,
institutions accurately account for and safeguard prescription medications,
institutions implement controls over ordering and receiving prescription medications, and
institutions comply with applicable laws and BOP policies.
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 BOP had 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 initiatives kept per capita costs from rising significantly.
The BOP’s costs for community provider services, medical guard escort services, and salaries continued to increase in spite of containment efforts; and the BOP needed to take additional actions to control some costs.
The OIG recommended that the BOP:
ensure that appropriate institutions are utilizing contract guard services,
instruct the wardens to review their mid-level practitioner and nurse staffing and restructure where appropriate, and
pursue the proposal of charging inmates a co-payment fee for medical services.
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.
Inmates with special needs, including women, psychiatric patients, and patients with chronic illnesses, were not receiving all of the health care services they needed because of staffing shortages.
Quality assurance programs identified actual and potential quality-of-care problems, but did not always include corrective action.
Physician assistants in the BOP lacked generally required education and certification and were not adequately supervised.
The BOP was planning a major hospital acquisition program without fully assessing whether inmates’ medical needs justified the acquisition and without planning how to recruit and retain the clinical staff necessary to operate these facilities.
The GAO recommended that the BOP:
prepare a needs assessment of the medical services required by inmates and determine the medical services it can efficiently and effectively provide in-house;
determine the most cost-effective approaches to providing appropriate health care to current and future inmate populations;
revise the BOP’s hiring standards for physician assistants to conform to current community standards of training and certification; and
re-emphasize to the wardens of medical referral centers the importance of taking corrective action on identified quality assurance problems.
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.
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.
“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)).
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.
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.
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.