OIG Audit Finds Major Deficiencies with BOP Health Care

by Brandon Sample

A comprehensive audit by the Department of Justice’s Office of the Inspector General (OIG) found numerous problems with the provision and management of medical services by the federal Bureau of Prisons (BOP).

The OIG’s latest audit focused on the effectiveness of measures taken by the BOP to control medical treatment costs, the quality of medical care provided to federal prisoners, contract administration, and the monitoring of BOP health care providers.

Since fiscal year 2000, the BOP has undertaken twenty initiatives to control medical costs, which reached $736 million during fiscal year 2007. Some of those initiatives included charging prisoners a $2.00 co-pay for health care visits, increased use of tele-medicine, implementation of an electronic medical records program, and the adoption of a Patient Care Provider Team (PCPT). Under the PCPT model, each BOP prisoner is assigned to a physician’s assistant. This approach is designed to improve the consistency of treatment and eliminate so-called “practitioner shopping” by prisoners.

In general, the OIG applauded the BOP for its cost-containment efforts. However, the auditors found the BOP had failed to maintain cost-related data for each of its initiatives, making it impossible to “assess the impact of each initiative individually.” As a result, the OIG recommended that BOP officials establish protocols for collecting and evaluating data for current and future health care initiatives to determine whether individual initiatives are cost-effective and producing the desired results.

Next, to assess whether the BOP was providing prisoners with appropriate care, the OIG looked at the BOP’s Clinical Practice Guidelines (CPG). There are 16 CPGs that cover various areas ranging from the management of diabetes, hypertension and coronary artery disease to preventative health care. Each CPG contains services that the Medical Director of the BOP expects institutions to provide. For the purpose of its audit, the OIG selected the Preventative Health Care CPG because it includes set criteria for medical services, which makes it easier to detect non-compliance.

OIG auditors visited five BOP facilities to evaluate whether required care was being provided: United States Penitentiary (USP) Atlanta, USP Lee, Federal Correctional Complex (FCC) Terre Haute, Federal Medical Center (FMC) Carswell, and FCC Victorville. The results from the site visits were troubling.

Of the 30 medical services required by the Preventative Health Care CPG, more than ten percent of prisoners did not receive care for 14 of 30 of the CPG services. For example, 94 percent of prisoners who should have received a cardiovascular risk calculation within the past five years had not. Similarly, 87 percent of prisoners born after 1956 had failed to receive a measles, mumps and rubella vaccine, while 64 percent of female prisoners had not been tested for chlamydia.

The OIG asked BOP officials at each of the five institutions why the CPG services had not been provided. FMC Carswell staff declined to offer an explanation. The other four institutions told the auditors that they had “overlooked the requirement,” “believed the procedure was too costly,” or blamed “staffing inadequacies and scheduling constraints” that precluded them from providing the medical services.

Failure to adopt the PCPT model was another factor that contributed to the non-provision of required services, the OIG report noted. Of the five institutions surveyed, only FMC Carswell had fully adopted the PCPT model. These deficiencies, according to the audit, indicated a “need for better BOP headquarters oversight and guidance.”

The OIG also examined the management of the BOP’s medical care contracts. As with prior audits, the OIG found major deficiencies with contract management. In one example, the auditors noted that seven BOP institutions lacked “critical controls” for certain contract administration functions, while about half of the institutions with critical controls failed to document their procedures associated with the controls. According to the OIG, the lack of adequate controls resulted in “questionable payments to contractors.”
Consequently, the audit recommended that the BOP strengthen controls over its contract administration and procedures to ensure that “systemic deficiencies are corrected.”

Finally, the OIG looked at the BOP’s monitoring of its health care providers. Of 40 internal audits conducted by the BOP, the OIG found that 25 separate medical services had not been provided to prisoners and 14 of those 25 deficiencies were noted at multiple institutions. In spite of these deficiencies, the BOP had failed to “develop or clarify agency-wide guidance on systemic weaknesses.”

In reviewing the current privileges, practice agreements and protocols for each of the BOP’s medical practitioners, the OIG auditors identified 134 practitioners who were allowed to provide medical services to prisoners without BOP privileges, practice agreements or protocols. Based on this data, the OIG concluded that “BOP officials do not fully understand the type of authorization different health care providers should receive, or ensure that the health care providers have them.”

Allowing practitioners to provide medical care without current privileges, practice agreements or protocols “increases the risk that practitioners may provide medical services without having the qualifications, knowledge, skills and experience necessary to correctly perform the services.” The OIG also noted that the BOP could face liability if improper medical care was provided by such practitioners.

The audit further found that 48 percent of BOP Clinical Directors, Chief Dental Officers and Clinical Psychiatrists had failed to undergo a peer review. As with the lack of privileges, practice agreements or protocols, failing to conduct peer reviews placed the BOP at “a higher risk of providers giving inadequate professional care to [prisoners], thus subjecting the BOP to formal complaints and lawsuits.”

Additionally, the audit noted that several BOP institutions were not submitting performance measures. Most institutions failed to provide an explanation for this failure while others attributed the problem to “staffing shortages.”

For those institutions that did report performance measures, nine of the measures fell below target levels for more than 20 percent of the quarters reported. Despite these deficits, no agency-wide corrective actions were taken by the BOP. The OIG stated it was essential that the BOP take corrective action when performance is “below targets to help ensure that [prisoners] are provided adequate medical care.”

In total, the OIG made 11 recommendations to the BOP regarding deficiencies found during the audit. BOP officials have accepted the recommendations, and the OIG has closed its audit report pending a review of corrective measures taken by the agency. See: OIG Audit Report No. 08-08 (The Federal Bureau of Prisons’ Efforts to Manage Inmate Health Care), February 2008. The report is posted on PLN’s website.

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