FBOP Efforts to Manage Inmate Health Care, DOJ OIG, 2008

• Feb. 16, 2016 • Locations: United States of America • Topics: Corrections Audits, Medical

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THE FEDERAL BUREAU OF PRISON’S
EFFORTS TO MANAGE INMATE
HEALTH CARE
U.S. Department of Justice
Office of the Inspector General
Audit Division
Audit Report 08-08
February 2008

THE FEDERAL BUREAU OF PRISONS’ EFFORTS
TO MANAGE INMATE HEALTH CARE
EXECUTIVE SUMMARY
The Federal Bureau of Prisons (BOP) is responsible for confining
federal offenders in prisons that are safe, humane, cost-efficient, and
secure. As part of these duties, the BOP is responsible for delivering
medically necessary health care to inmates in accordance with applicable
standards of care.
As of November 29, 2007, the BOP housed 166,794 inmates in 114
BOP institutions at 93 locations.1 During FY 2007, the BOP obligated about
$736 million for inmate health care. The BOP provides health care services
to inmates primarily through: (1) in-house medical providers employed by
the BOP or assigned to the BOP from the Public Health Service, and
(2) contracted medical providers who provide either comprehensive care or
individual services.
To control the rising cost of health care, since the early 1990s the BOP
has implemented initiatives aimed at providing more efficient and effective
inmate health care. The BOP’s on-going initiatives include assigning most
inmates to institutions based on the care level required by the inmate,
installing an electronic medical records system that connects institutions,
implementing tele-health to provide health care services through video
conferencing, and implementing a bill adjudication process to avoid costly
errors when validating health care-related 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.
OIG Audit Approach
The Department of Justice Office of the Inspector General (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

Appendix V contains a list of the Bureau of Prisons (BOP) institutions. The BOP
housed an additional 33,354 inmates in privately managed, contracted, or other facilities.
For the purposes of this audit, we focused on the medical care provided to inmates housed
in BOP facilities.

services contracts; and (3) effectively monitored its medical services
providers.
We performed audit work at BOP headquarters and at the following
BOP institutions: the United States Penitentiary (USP) Atlanta (Georgia),
USP Lee (Virginia), Federal Medical Center (FMC) Carswell (Texas), Federal
Correctional Complex (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 in a cost-effective manner. 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.
Results in Brief
We found that the BOP has implemented or begun numerous cost
containment initiatives since fiscal year (FY) 2000 that appear to have
helped it contain inmate health care costs. Although the BOP generally did
not maintain analytical data to assess the impact that the individual
initiatives had on health care costs, our audit found that the BOP has kept
the growth of inmate health care costs at a reasonable level compared to
national health care cost data reported by the Departments of Health and
Human Services and Labor.
However, we also determined that each of the BOP institutions we
tested did not always provide recommended preventive health care to
inmates. Our audit found that for almost half of the preventive health
services we tested, more than 10 percent of the sampled inmates did not
receive the medical service.
In addition, OIG audits of BOP medical contracts have found multiple
contract-administration deficiencies, such as inadequate review and
verification of contractor billing statements. Several of the contractadministration deficiencies appeared to be systemic. While the BOP had
taken action to address individual deficiencies at local institutions, we also
found that other BOP institutions lacked appropriate controls in the
deficiency areas identified by prior OIG contract audits.

We also identified weaknesses in the BOP’s monitoring of health care
providers. Specifically, the BOP: (1) did not develop agency-wide guidance
to correct apparent systemic problems found during medical-related internal
reviews and external audits; (2) did not provide health care providers with
current authorization to practice medicine on BOP inmates through
privileges, practice agreements, or protocols; (3) had not performed
required initial and renewal peer reviews for providers; and (4) had not
implemented an effective performance measurement system related to the
provision of health care at BOP institutions.
In our report, we make 11 recommendations regarding the BOP’s
provision of medical care for inmates. These recommendations include:
establishing procedures to assess whether individual initiatives are costeffective and producing the desired results; determining the necessity of
performing medical services that generally were not performed by most BOP
institutions; providing guidance and procedures to all BOP institutions for
performing certain contract administration functions related to inmate health
care; and ensuring that privileges, practice agreements, or protocols are
established for all practitioners, as applicable.
The remaining sections of this Executive Summary describe in more
detail our audit findings.
Cost Containment
Since FY 2000, the BOP has implemented or developed at least
20 initiatives designed to improve the delivery of health care to inmates,
improve the administration and management of health care, and reduce or
contain rising health care costs. As of December 2007, the BOP had
implemented 11 of these initiatives and was in the process of implementing
the remaining 9 initiatives.
In the following table, we provide a description of four of the BOP’s
major initiatives. Appendix II contains a description of the 20 initiatives.

iii

Initiative
Medical Designations
Program

Medical Staff
Restructuring

Tele-medicine
Electronic Medical
Records

We attempted to determine the effect that the BOP’s initiatives had on
inmate health care costs. However, while the initiatives had a primary or
secondary purpose of reducing or containing health care costs, the BOP
could not provide either preliminary cost-benefit analyses or any postimplementation analyses to identify costs reduced or contained by these
initiatives. BOP officials believed that preliminary cost-benefit analyses had
been performed, but said the documentation of the analyses was no longer
available. As for post-implementation analyses, BOP officials told us that the
BOP does not collect and maintain cost-related data that would allow it to
analyze the cost-effectiveness of each of its health care initiatives. As a
result, we recommend that the BOP collect cost-related data for each
initiative and use the data collected to analyze whether the initiatives are
providing the anticipated cost benefits.
Because the BOP did not maintain cost data for its health care
initiatives, we were also unable to assess the impact of each initiative
iv

individually. Instead, we analyzed the overall effect of the BOP’s initiatives
on total medical costs. We compared the BOP’s per capita health care costs
for calendar years 2000 through 2006 to similar data reported by the
Department of Health and Human Services (HHS) and the Department of
Labor (DOL). We found that although the BOP experienced growth in excess
of the HHS national average for medical costs and the DOL Consumer Price
Index (CPI) for medical costs during some of the earlier years of our review
period, the BOP’s growth rates since 2002 have declined significantly, even
though the growth rates in the HHS national average and the DOL CPI have
not. The following graph shows the results of our comparison.
Comparison of the Growth Rates of Health Care Costs for BOP HHS, and DOL
Health Care Data for Calendar Years 2000 through 20062
9%
8%

G
r
o
w
t
h

R
a
t
e

6%
5%

BOP

HHS

DOL

1%
0%
-1%

-2%

2000 - 2001 - 2002 2001

2002

2003

2003 - 2004 - 2005 2004

2005

2006

Calendar Years
Source: BOP Office of Research and Evaluation, BOP Budget Execution
Branch, Department of Health and Human Services, and Department of Labor

The above comparison indicates that the BOP has been effective in
containing the growth of health care costs.

The BOP’s, the Department of Health and Human Services’ (HHS) and the
Department of Labor’s (DOL) per capita health care medical costs are not fully comparable.
The BOP’s medical per capita costs include costs for services not included in HHS’s and the
DOL’s per capita medical costs and vice versa. Even though the costs are not fully
comparable between the three measures, we believe the cost measures are sufficiently
similar for comparison purposes. The HHS national average cost data was obtained from
the HHS report, National Health Expenditures Aggregate, Per Capita Amounts, Percent
Distribution, and Annual Percent Change by Source of Funds: Calendar Years 2005 – 1960
(January 2007). An updated report showing cost data for 2006 was not available.

Preventive Health Care
The BOP periodically develops program statements to disseminate
policy on a variety of BOP programs. Appendix VI contains a brief
description of the BOP program statements related to the provision of
medical, dental, and mental health services to inmates.
The BOP has also established 16 clinical practice guidelines containing
diagnostic procedures for specific medical areas, such as preventative health
care, coronary artery disease, and hypertension. The Introduction section of
this audit report contains a list of the 16 medical areas covered by the
clinical practice guidelines. While the guidelines have not been incorporated
into the BOP’s program statements as policy, the BOP Medical Director told
us that BOP institutions are expected to provide the services in the
guidelines to the inmates. The Medical Director also told us that the
institutions have discretion in whether to follow the guidelines on a case-bycase basis. However, BOP institutions must request and receive approval
from the Medical Director to not implement a specific guideline requirement.
To determine whether the institutions were providing expected
medical services to inmates, we selected and tested specific medical services
listed in the BOP’s Preventive Health Care Clinical Practice Guideline. We
chose this particular BOP guideline because:
•

It addressed care for all inmates, instead of only inmates with
specific illnesses;

•

It included diagnostic procedures for 9 of the 11 chronic conditions
addressed in the other 15 guidelines;

•

It contained clearly defined medical services that could be
reasonably tested;

•

Health promotion and disease prevention is a primary objective of
the BOP’s efforts to contain costs; and

•

The BOP Medical Director told us that testing of the preventive
health care guideline would provide useful information to the BOP
because its per capita cost of providing health care should be
reduced by implementing a good preventive health program, and
he expects the institutions to provide the services contained in the
guideline.

We specifically selected and tested 30 medical services contained in
the preventive health care guideline, including whether: (1) inmates
received a measles, mumps, and rubella vaccine; (2) inmates received a
hepatitis A vaccine; (3) inmates received a cholesterol check in the last 5
years; (4) female inmates received a chlamydia test; and (5) female
inmates received a bone density screening test.3
To perform our testing of the 30 medical services, we selected a
sample of 1,110 of the 14,026 inmates assigned to 5 BOP locations as of
March 24, 2007, as shown in the table below. Appendix IV contains an
explanation of our sampling methodology.
Inmate Population and Inmates Sampled
Inmate
Population
as of
March 24, 2007
2,494
1,808
3,343
1,677
4,704
14,026

BOP Facility
USP Atlanta (Georgia)
USP Lee (Virginia)
FCC Terra Haute (Indiana)
FMC Carswell (Texas)
FCC Victorville (California)
Totals

Inmates
Sampled
251
133
249
127
350
1,110

Source: OIG sample from BOP inmate population data

For each inmate sampled, we reviewed the inmate’s medical record
and determined whether the inmate received the 30 preventive services, as
applicable. The 30 services were not applicable to all inmates sampled for
reasons such as certain services applied to only female inmates, certain
services were only for inmates over a certain age, and other services applied
only if the inmate had certain risk factors. To validate our testing, we asked
a Health Services Unit official at each of the facilities tested to confirm our
results and ensure that we had not overlooked the provision of any service.
While the BOP guideline suggests that all inmates should receive the
applicable services, we recognize that 100 percent compliance is unlikely
given the movement of inmates between prisons, staffing shortages, and
other reasons. Therefore, we noted a deficiency when 10 percent or more of
the inmates for whom the service was applicable had not received it.
As demonstrated in the following two charts, the combined results for
all 5 locations showed that for 16 of the 30 services tested, 90 percent or
more of the inmates received the preventive service as appropriate. For the
3

Appendix III shows all 30 medical services we tested.

vii

remaining 14 services, more than 10 percent of the sampled inmates did not
receive the medical service.4 For example, 94 percent of the inmates who
should have received a cardiovascular risk calculation had not received one
in the last 5 years, as recommended by BOP guidelines. Additionally, 87
percent of the sampled inmates needing a measles, mumps, and rubella
vaccine had not received this service.
Overall Results of the OIG’s Testing of
Medical Services Provided to Inmates5

Medical Service Tested

Yes

Inmates
Tested

1. Inmate medical history
provided by inmate at intake

1,044

99%

2. Medical assessment completed
by medical practitioner at intake

1,044

99%

3. New inmate tested for
tuberculosis or previous test for
transferred inmate confirmed,
within 48 hours of intake

1,043

99%

4. Inmate received rapid plasma
regain test during intake screening
to test for syphilis
5. Female inmate tested for
chlamydia

6. Female inmate received a
measles/mumps/rubella vaccine

128

7. Inmate received a complete
physical within 14 days of intake

1,044

8. Inmate received a
pneumococcal vaccine

9. Inmate received an annual
influenza vaccine

210

10. Inmate born after 1956 received
a measles/ mumps/rubella vaccine

932

11. Inmate received a tetanus
vaccine in the last 10 years

92%

403

36%

64%
81%

19%

95%

74%

23%

71%
13%

29%
87%
49%

50%

1,042

12. Inmate received a hepatitis A
vaccine

263

13. Inmate received a hepatitis B
test or vaccine

343

90%

14. Inmate received a hepatitis C
test

267

91%

57%

42%

The percentages in the chart are based on the number of inmates for whom the
service was applicable.
5

Some percentages in the chart total less than 100 percent because documentation
was not available to determine if the service was performed for some inmates.

viii

Medical Service Tested

Inmates
Tested

Yes

15. Inmate received an HIV-1 test

381

16. Inmate received an HIV-2 test

130

98%

17. Inmate received a tuberculosis
test in the past year

869

98%

18. Inmate received a chronic care
evaluation in the last 6 months

339

19. Inmate received a cholesterol
check in the last 5 years

678

20. Inmate received a cardiovascular
402
risk calculation in the last 5 years

93%

98%

94%
84%

1,043

23. Inmate received a current
body mass index calculation

1,036 12%

26. Inmate received a hearing
screening test

27. Inmate received an
abdominal ultrasound test

28. Female inmate received a
papanicolaou test (PAP smear)

30. Female inmate received a
bone density screening test

88%
54%

46%

93%
51%

49%
100%
1%

99%

142

29. Female inmate received a
current mammogram

12%

96%

189
58

29%

22. Inmate received a current
blood pressure check

25. Inmate received a vision
screening test

71%

21. Inmate received a fasting plasma
324
glucose test in the last 3 years

24. Inmate received a fecal
occult blood test

100%
38%

62%

Source: OIG testing of BOP medical records

We found that the institutions either did not usually provide or were
inconsistent in providing 18 of the 30 medical services we tested. For
example, the cardiovascular risk calculation was rarely performed in the 5
institutions we tested. Moreover, as shown in the chart below, we found
that the percentage of applicable inmates not receiving a cholesterol check
within the past 5 years ranged from 68.1 percent at USP Lee to 8.3 percent
at FMC Carswell. This disparity in medical service provision indicates a need
for better BOP headquarters oversight and guidance.

Percent of Applicable Inmates NOT
Receiving a Cholesterol Check in Last 5 Years
Inmates
Tested
29%

135

USP Atlanta
8% FMC Carswell

72
68%

USP Lee
13%

187

FCC Terre Haute
FCC Victorville

36%

215
100

Percent

Source: OIG testing of BOP medical records

We asked officials at each of the five locations for an explanation of
why some services were not provided to a significant number of inmates.
FMC Carswell medical officials declined our requests for an explanation,
stating that BOP headquarters would provide a response after we issued our
report. The following are examples of explanations given to us by officials
from the other four locations.
•

The vaccine was not always available to give to the inmate.

•

The officials believed that a requirement applicable to all inmates
only applied to women.

•

The officials used alternative methods in place of certain services.

•

The officials considered the service unnecessary.

•

The inmates failed to return the test cards.

•

The officials overlooked the requirement.

•

The officials believed the procedures were too costly.

•

Staffing inadequacies and scheduling constraints precluded the
officials from providing the service.

Another factor that could have contributed to expected medical
services not being provided consistently is that four of the five institutions
had not fully implemented the Primary Care Provider Teams (PCPT) as
required by the BOP’s patient care policy. Under the PCPT model, each
inmate is assigned to a medical team of health care providers and support
staff who are responsible for managing the inmate’s health care needs. The
x

PCPT model is designed to provide inmates with better and more consistent
medical care because the inmate is examined by the same provider team
each time the inmate requires medical attention. If the same provider team
examines an inmate during each visit, the inmate should be less likely to
miss some services because the provider team would be familiar with the
services previously provided to the inmate. According to the BOP’s
Preventive Health Care Clinical Practice Guideline, the most efficient and
cost-effective way to implement the guideline is to assign appropriate
responsibilities to each PCPT member. However, we found that only the FMC
Carswell had implemented the PCPT concept. The other four institutions had
not fully implemented the PCPT concept primarily because of limited staffing.
Contract Administration
The BOP relies on contractors to provide a substantial amount of
medical services to inmates, and the OIG periodically performs audits of the
BOP’s comprehensive medical contracts. From August 2004 through March
2007, the OIG issued nine audit reports on BOP medical contracts. Appendix
X contains a summary of these audits. Eight of the nine OIG contract audits
identified major internal control deficiencies. The deficiencies included
management control weaknesses pertaining to calculating medical service
discounts, reviewing and verifying contractor invoices and billing
statements, paying bills, and managing the overall administration of the
contracts. The audits indicated several of the weaknesses were systemic,
such as:
•

Six of the contract audits found weaknesses in verifying and
reviewing the accuracy of invoices for medical services provided by
the contract providers.

•

Five of the contract audits found weaknesses in obtaining
supporting documentation for contractor billing statements.

•

Four of the contract audits found errors in the Medicare or
diagnostic-related groups discount rates.

•

Three of the contract audits found that the contractor did not
provide the services stated in the contract, and the contractor’s
performance reports were either inaccurate or submitted in an
untimely fashion.

The audits usually found that the identified weaknesses were
attributable to the lack of written procedures and other internal controls. As
of November 2007, the BOP had implemented corrective actions for all the
xi

recommendations in seven of the nine contract audits. For the other two
audits the BOP agreed to take corrective actions concerning our
recommendations, and those actions were either completed or in progress as
of November 2007. In response to six of the nine audits, the BOP
strengthened management controls by establishing written procedures for
processing and monitoring contract medical claims. However, these actions
were limited to correcting the deficiencies only at the institutions where the
deficiencies were found.
As part of this larger audit of BOP medical services we tested whether
the BOP as a whole had strengthened controls related to the deficiencies
identified in the contract audits. We interviewed BOP officials at the five
BOP locations tested. For the remaining 88 BOP locations, we sent survey
questionnaires and asked whether the institutions had established
management control procedures for their comprehensive medical contracts,
including:
•

reviewing contractor invoices for accuracy,

•

ensuring contractor invoices are supported by adequate
documentation,

•

ensuring that invoice discounts are properly applied,

•

ensuring that contractor performance reports are complete and
accurate, and

•

ensuring that contractor timesheets are verified by a BOP
employee.

We found that up to seven BOP institutions lacked critical controls for
certain contract administration functions, and about half the institutions with
critical controls had not documented the procedures associated with the
controls.
Our analysis of survey responses found that 77 of the 88 BOP
institutions surveyed had comprehensive medical service contracts.
Generally, officials at each institution responded that they had established
internal control procedures for administering its contracts. However, we
found that about half the institutions had not formalized these procedures in
written policy for the controls we tested, as noted in the chart below.

xii

Controls Established by BOP Institutions for
Comprehensive Medical Services Contracts
Number of Institutions
Procedures
Established
Procedures
but not
Established
Written

Contract
Procedures
Administration
not
Function
Established
Reviewing contractor
invoices for accuracy
1
76
Ensuring contractor
invoices are supported
by documentation
3
74
Ensuring invoice
discounts are properly
applied
7
70
Ensuring contractor
performance reports are
complete and accurate
2
75
Ensuring contractor
timesheets are verified
by a BOP employee
2
75
Source: BOP responses to OIG survey questionnaire

Percent of
Established
Procedures
not Written

51%

49%

47%

57%

The lack of written procedures increases the risk that appropriate
controls will not be fully and consistently implemented, especially when staff
assignments and duties change. We found during our medical service
contract audits that the lack of management controls resulted in
questionable payments to contractors, and we believe it is possible based on
these results that similar errors may have occurred for medical contracts in
other BOP facilities. It is essential that the BOP strengthen controls over
administering its contracts by providing guidance and procedures to its
institutions to help ensure that systemic deficiencies are corrected BOP-wide.
Monitoring Health Care Providers
The BOP has established numerous mechanisms to monitor its health
care providers. Some of the mechanisms include:
•

conducting internal program reviews to determine whether each
institution is properly implementing BOP policies, including policies
related to inmate health care;

xiii

•

granting clinical privileges and establishing practice agreements and
protocols based on health care providers’ qualifications, knowledge,
skills, and experience;6

•

conducting peer reviews of health care providers to review the
current knowledge and skills of the providers; and

•

requiring each institution to accumulate and report performance
data on a quarterly basis for specific health-related areas.

The primary purpose of these monitoring mechanisms is to improve
the quality and efficiency of health care delivered to inmates by:
(1) identifying and correcting deficiencies in the provision of health care, and
(2) authorizing duties for health care providers commensurate with their
skills and capabilities.
Our audit found that the BOP corrects deficiencies at the institutions at
which deficiencies are found, but generally does not develop and issue
agency-wide guidance to correct systemic deficiencies found during internal
program reviews. We also found that the BOP allowed several health care
providers to practice medicine without valid authorizations. Additionally,
providers had not had their medical practices evaluated by a peer as
required by BOP policy. Moreover, while institutions were accumulating and
reporting data on health-related performance measures, the BOP does not
develop agency-wide corrective actions when the performance is below
target levels. These issues are summarized in the following sections.
Program Reviews
The BOP’s Program Review Division monitors health care services
provided to inmates through periodic reviews generally conducted once
every 3 years, or more frequently if significant problems are identified.
From FYs 2004 to 2006, the Program Review Division conducted 110 health
care program reviews at 88 BOP locations. We analyzed the 110 review
reports and determined that 40 of the 110 reviews found medical services
deficiencies. The Program Review Division required institutions to certify
completion of corrective actions for the deficiencies identified.
The Program Review Division also prepared quarterly summary reports
of the program reviews. The summary reports identified the most frequent
deficiencies found during the reviews and were distributed to the Chief
6

Clinical privileges and practice agreements authorize the specific clinical or dental
duties that health care providers may provide to BOP inmates.

xiv

Executive Officers within the BOP, including the Health Services Division
Medical Director. However, a senior Health Services Division official told us
that the BOP probably would not change its policy when program reviews
find problems in a certain area, but it might provide training to improve staff
knowledge and compliance. The official told us that the Health Services
Division relies on the BOP Regional Offices and institutions to correct
identified problems.
We analyzed the 40 BOP reviews and found that 25 different medical
services were not provided to inmates and 14 of the 25 deficiencies were
noted at multiple institutions. For example, as shown in the table on page
32 of this report, the Program Review Division found inmates with chronic
care conditions who were not monitored as required at 16 institutions. Also,
the reviews found inmates who were not monitored for psychotropic medical
side effects at 11 institutions. We believe the BOP should use the program
summary reports prepared by the Program Review Division to develop or
clarify agency-wide guidance on systemic weaknesses and issue the
guidance to all BOP institutions.
Privileges, Practice Agreements, and Protocols
In the provision of inmate health care, BOP institutions use the
following health care providers.
•

Licensed independent practitioners are medical providers
authorized by a current and valid state license to independently
practice medicine, dentistry, optometry, or podiatry.

•

Non-independent practitioners are graduate physician assistants
(certified or non-certified), dental assistants, dental hygienists,
nurse practitioners, and unlicensed medical graduates.

•

Other practitioners are those not included in the above categories
and include clinical nurses and emergency medical technicians.

To improve the quality of medical care that these medical providers
provide to inmates, the BOP: (1) grants clinical privileges to licensed
independent practitioners based on the practitioner’s qualifications,
knowledge, skills, and experience; (2) establishes practice agreements
between its licensed independent practitioners and its non-independent
practitioners, such as mid-level practitioners; (3) establishes protocols that
must be followed by other health care providers; and (4) performs periodic
peer reviews of all providers who function under clinical privileges or practice
agreements.
xv

The BOP grants clinical privileges to its in-house and contracted
practitioners. Clinical privileges are the specific duties that a health care
provider is allowed to provide to BOP inmates. BOP policy states that clinical
privileges can be granted for a period of not more than 2 years, and that
newly employed physicians can be granted privileges for a period of not
more than 1 year. Practitioners are prohibited from practicing medicine
within the BOP until they have been granted privileges to do so by an
authorized BOP official.
The individual institutions establish practice agreements between their
licensed independent practitioners and their non-independent practitioners.
Practice agreements delegate specific clinical or dental duties to
non-independent practitioners under a licensed independent practitioner’s
supervision and are valid for no more than 2 years. Non-independent
practitioners are prohibited from providing health care within the BOP until a
practice agreement has been established.
The BOP’s other health care providers, such as clinical nurses and
emergency medical technicians, must work under protocols approved by
licensed independent practitioners. A protocol is a plan for carrying out
medical-related functions such as a patient’s treatment regimen.
To determine whether the BOP maintained current privileges, practice
agreements, and protocols for each of its practitioners, we included relevant
questions in our survey questionnaire sent to 88 BOP institutions. Based on
the responses to our questionnaires, we identified 134 practitioners out of
1,536 (9 percent) who were allowed to provide medical services to BOP
inmates without current BOP privileges, practice agreements, or protocols.
BOP Medical Practitioners without Current
Privileges, Practice Agreements, or Protocols
Type of
Authorizing
Document
Privileges
Practice Agreement
Protocol
Totals

Practitioners
Requiring
Authorizing
Document
680
466
390
1,536

Practitioners
without
Authorizing
Document
72
42
20
134

Percent
without
Authorizing
Document
11%
9%
5%
9%

Source: Responses by BOP institution officials to OIG survey questionnaire

Based on this data, it is apparent 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.

xvi

Allowing practitioners to provide medical care to inmates without
current privileges, practice agreements, or protocols increases the risk that
the practitioners may provide medical services without having the
qualifications, knowledge, skills, and experience necessary to correctly
perform the services. In addition, the BOP could be subjected to liability
claims by inmates if improper medical services are provided by these
practitioners.
Peer Reviews
BOP policy requires that BOP health care providers have a periodic
peer review. A peer is defined as another provider in the same discipline
(physician, dentist, mid-level practitioner, or others) who has firsthand
knowledge of the provider’s clinical performance. The peer review should
evaluate the professional care the provider has given using a sample of the
provider’s primary patient load and comment on specific aspects of the
provider’s knowledge and skills, such as actual clinical performance,
judgment, and technical skills. BOP health care providers who are privileged
or working under a practice agreement must have at least one peer review
every 2 years. Each Clinical Director, Chief Dental Officer, and Clinical
Psychiatrist must also have a peer review at least once every 2 years.
In our survey questionnaire sent to 88 BOP institutions, we requested
the last peer review date for all providers with privileges or practice
agreements. For the 891 such providers, the responses to the questionnaire
indicated that 430 (48 percent) had not received a current peer review. We
asked BOP officials about the lack of peer reviews. The officials responsible
for more than half of the non-current peer reviews did not provide an
explanation. The officials responsible for the remaining non-current peer
reviews cited the following reasons.
•

The officials rely on contractors to do peer reviews.

•

The officials believed that the peer review requirement did not
apply to mid-level practitioners, dental assistants, or dental
hygienists.

•

The officials relied on performance reviews instead of doing the
required peer reviews.

Without a current peer review, the BOP has a higher risk of providers
giving inadequate professional care to inmates, thus subjecting the BOP to
formal complaints and lawsuits. Also, if inadequate professional care goes

xvii

undetected, the providers may not receive the training or supervision
needed to improve the delivery of medical care.
Performance Measures
The BOP has also established national performance measures for
health care to include annual targets or goals for management of:
(1) hypertension, (2) cholesterol, (3) diabetes, (4) HIV, (5) tuberculosis,
(6) asthma, (7) breast cancer, (8) cervical cancer, and (9) pregnancy. The
BOP institutions voluntarily report results for these performance measures to
the BOP Health Services Division on a quarterly basis.
In our survey questionnaire, we asked institution officials if they had
completed the performance measure calculations for the nine performance
measures for calendar year 2004 through the first quarter of calendar year
2007. The following table details the 99 responses from officials at the 88
BOP locations.7
Performance Measure
Calculations Completed
for Calendar Year
2004
2005
2006
2007 (1st Quarter)

Yes
59
77
87
90

No
28
14
11
7

BOP Response
Not
No
Applicable
Response
10
2
4
4
0
1
1
1

Source: BOP responses to OIG survey questionnaires

Based on the responses, the number of institutions not completing the
performance measure calculations decreased each year since 2004.
However, when asked why the calculations were not always completed, BOP
officials usually could not provide an explanation and said that the person
who was responsible for completing the calculations was no longer at the
institution. The officials who did provide an explanation usually attributed
not completing the performance measure calculations to staffing shortages.
We also analyzed the performance measure reports from the BOP and
found that the institutions often did not meet the target levels established
for the nine target goals. For the nine health care performance measures
we tested, we found that the institutions reported performance below the
target level for more than 20 percent of the quarters reported for seven of
7

The total responses (99) to our survey questions was more than the 88 BOP
locations surveyed because 6 of the locations surveyed submitted separate responses for
the 17 BOP institutions at the locations. Performance measures were not applicable for
some institutions primarily because the institutions are new and were not active for the
years tested.

xviii

the nine performance measures. For example, for the clinical management
of lipid level measure, 79 institutions reported results for 723 quarters
between January 1, 2004 and March 31, 2007. The results reported were
below the target level for 437 (60 percent) of the quarters reported. In
another example related to the clinical management of diabetes, the 79
institutions reported below target level performance for 285 (39 percent) of
the 729 quarters reported.
We discussed with BOP Health Services Division officials their review of
and response to the performance reports. The officials told us that they
review the reports, perform a trend analysis, and summarize the results in
the Office of Quality Management’s Annual Report. However, the officials
also told us that institution participation in reporting the performance
measures is voluntary and they do not develop agency-wide corrective
actions when the performance is below target levels. We believe it is
essential that the BOP take corrective actions when performance is below
targets to help ensure that inmates are provided adequate medical care.
In addition, we found that instructions are needed to help ensure
performance data are consistently accumulated and reported. The BOP did
not provide institutions with instructions on accumulating and reporting such
data. According to a BOP Health Services Division official, the institutions
are inconsistent in how they accumulate and report performance data. If
this is the case, the summary data compiled by the BOP may not be
meaningful. This BOP Health Services Division official also told us that
because of the inconsistencies in data reported, the BOP is developing a
training program to educate institution staff on how to properly accumulate
and report performance data. According to the Chief of the BOP’s Quality
Management Section, a meeting was held in December 2007 with the
institution Health Services Administrators to discuss the collecting of national
performance measure data. Another meeting is planned for January 2008 to
discuss with Regional Medical Directors any adjustments needed to the
performance measurement system.
Conclusion and Recommendations
In general, we found that in comparison to other national health care
cost indices, the BOP was successful at containing the growth of inmate
health care costs. However, our audit concluded that the BOP could make
improvements to help ensure that: (1) inmates are provided recommended
preventative medical care, (2) contract administration deficiencies are
addressed BOP-wide, and (3) monitoring of medical service providers is
strengthened. If the deficiencies we noted in these areas are not corrected,
we believe the BOP could experience:
xix

•

higher costs for providing health care,

•

decreases in the quality of health care,

•

a higher number of medical-related complaints from inmates, and

•

greater liability for lack of adequate medical care.

To assist the BOP in improving medical care for inmates, we made 11
recommendations to the BOP. These recommendations include:
(1) establishing procedures for collecting and evaluating data for current and
future health care initiatives to assess whether individual initiatives are costeffective and producing the desired results; (2) reviewing the medical
services that the OIG and the BOP’s Program Review Division identified as
not always provided to inmates and determining whether the medical
services are necessary or whether the medical service requirement should
be removed from the program statements or clinical practice guidelines, as
appropriate; (3) providing additional guidance to the institutions to ensure
that medical services deemed necessary are provided to the inmates,
(4) providing additional guidance and procedures to all BOP institutions for
performing certain contract administration functions; (5) developing and
issuing agency-wide guidance to correct systemic deficiencies found during
internal program reviews; and (6) ensuring that privileges, practice
agreements, or protocols are established for all practitioners, as applicable.

TABLE OF CONTENTS
Page
INTRODUCTION ............................................................................. 1
Health Care Responsibilities............................................................ 2
Health Care Costs ......................................................................... 3
Controlling Health Care Costs ......................................................... 4
The Provision of Health Care Services .............................................. 4
Necessary Medical Care ................................................................. 5
BOP Policy Guidance...................................................................... 8
Prior Audits, Inspections, and Reviews ............................................. 9
OIG Audit Objectives and Approach ............................................... 14
FINDINGS AND RECOMMENDATIONS............................................

1. HEALTH CARE DELIVERY AND COST IMPACT........................ 15
Improving the Delivery of Health Care to Inmates ........................... 15
Cost Impact of the BOP’s Health Care Initiatives.............................. 21
Providing Medical Services to Inmates............................................ 24
Conclusion ................................................................................... 34
Recommendations......................................................................... 35
2. BOP CONTRACT ADMINISTRATION ...................................... 37
Conclusion ................................................................................... 42
Recommendation .......................................................................... 42
3. MONITORING BOP HEALTH CARE PROVIDERS .....................
The BOP’s Program Review Results................................................
The BOP’s Credential Verification, Privileges, and Practice
Agreement Program ................................................................
The BOP’s Health Care Performance Measures.................................
Conclusion .................................................................................
Recommendations.......................................................................

45
46

STATEMENT ON COMPLIANCE WITH LAWS AND REGULATIONS ....

STATEMENT ON INTERNAL CONTROLS..........................................

ACRONYMS AND ABBREVIATIONS ................................................

47
51
54
55

APPENDIX I – Audit Objectives, Scope, and Methodology .............

APPENDIX II – BOP Initiatives since FY 2000 to Improve the
Effectiveness and Efficiency of Inmate Health Care ..................

APPENDIX III – Medical Services Selected for Testing from the
BOP’s Preventive Health Care Clinical Practice Guideline ..........

APPENDIX IV – Sample Methodology ...........................................

APPENDIX V – BOP Institutions and Inmates Housed as of
November 29, 2007..................................................................

APPENDIX VI – Summary of BOP Program Statements Related
to the Provision of Medical, Dental, and Mental Health
Services ...................................................................................

APPENDIX VII – Results of the OIG’s Testing of the Provision
of Medical Care at BOP Institutions ..........................................

APPENDIX VIII – The BOP’s Health Care Performance Measures ..

APPENDIX IX – Types of BOP Institutions ................................... 101
APPENDIX X – Department of Justice, Office of the Inspector
General Audits of BOP Medical Contracts from August 2004
through March 2007................................................................ 103
APPENDIX XI – The BOP’s Response to the Draft Audit Report .... 111
APPENDIX XII – Office of the Inspector General, Audit Division,
Analysis and Summary of Actions Necessary to Close the
Report..................................................................................... 117

INTRODUCTION
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.
BOP Facilities
WA
ME

MN
ID

V
T

N
H

RI
CT

IA
CA

NE
UT

OH
IL

WV
MO

OK
AR

SC
MS

NJ
DE

AL
GA

PR
HI

Source: OIG mapping of BOP facilities based on data provided by the BOP
8

This audit focused on the medical care provided to only those inmates housed in
Bureau of Prison (BOP) facilities.

Health Care Responsibilities
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

Estelle v. Gamble, 429 U.S. 97, 97 S. Ct. 285, 50 L. Ed. 2d 251 (1976).

“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)).

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.

Health Care Costs
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.
BOP Health Care Costs
FYs 2000 through 2007

$800M
$573M $624M

$600M
$400M

$413M

$453M

$736M
$654M $686M

$515M

Operations
Salaries

$200M
$0M

2000

2001

2002

2003

2004

2005

2006

Fiscal Year
Source: BOP Budget Execution Branch

2007

Controlling Health Care Costs
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 Provision of Health Care Services
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
Necessary Medical Care
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
11

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.

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;
hemorrhage;
stroke;
precipitous labor or complications associated with pregnancy;
and
o detached retina, sudden loss of vision.
o
o
o
o
o

•

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:
o serious deterioration leading to premature death;
o significant reduction in the possibility of repair later without
present treatment; or
o significant pain or discomfort, which impairs the inmate’s
participation in activities of daily living.
Examples of conditions considered medically necessary –
non-emergent include but are not limited to:
o chronic conditions (diabetes, heart disease, bipolar disorder,
schizophrenia);
o infectious disorders in which treatment allows for a return to
previous state of health or improved quality of life (HIV,
tuberculosis); and
o 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:
6

o joint replacement;
o reconstruction of the anterior cruciate ligament of the knee;
and
o treatment of non-cancerous skin conditions, such as skin tags
and lipomas.
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:
o
o
o
o
•

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:
o minor conditions that are self-limiting,
o cosmetic procedures, or
o removal of non-cancerous skin lesions.
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.

•

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.

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.

Any treatment provided in this category requires the BOP Medical
Director’s review and approval with notification to the Regional
Director.
BOP Policy Guidance
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

•

Diabetes

•

Gastroesophageal Reflux Disease Dyspepsia and Peptic Ulcer
Disease

•

Management of Headaches

•

Viral Hepatitis

•

Management of Human Immunodeficiency Virus (HIV)

•

Hypertension

•

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.

Prior Audits, Inspections, and Reviews
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.

Department of Justice, Office of the Inspector General, The Federal Bureau of
Prisons Pharmacy Services, Audit Report Number 06-03 (November 2005).

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.

Department of Justice, Office of the Inspector General, Inmate Health Care Costs
in the Bureau of Prisons, Inspections Report Number I-97-01 (November 1996).
15

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.

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 costeffective 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

Tele-medicine is a method of providing health care from a remote location using
technology such as video conferencing modified to include peripheral devices that produce
images of diagnostic quality.
17

The BOP implemented the $2 fee for inmate health care visits as discussed in
more detail on page 20 of this report.
18

The “Medicare federal rate” is a common or standard benchmark rate for specific
medical services identified in Medicare diagnosis-related groups.
19

U.S. General Accounting Office, BUREAU OF PRISONS HEALTH CARE, Inmates’
Access to Health Care Is Limited by Lack of Clinical Staff, GAO/HEHS-94-36 (February
1994), 1.

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 qualityof-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.

OIG Audit Objectives and Approach
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 onsite 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.

FINDINGS AND RECOMMENDATIONS
1. HEALTH CARE DELIVERY AND COST IMPACT
The BOP has implemented multiple cost containment strategies
over the past several years to provide health care to inmates in
a more effective and efficient manner. However, the BOP
generally did not maintain analytical data to assess the impact
that the individual initiatives had on health care costs. Yet, our
audit found that the BOP has kept the growth of inmate health
care costs at a reasonable level compared to national health care
cost data reported by the Departments of Health and Human
Services and Labor. With respect to inmate health care, we
found that BOP institutions did not always provide recommended
preventive medical services to inmates. We also found that BOP
institutions did not consistently provide medical services
recommended by BOP guidelines to inmates.
Improving the Delivery of Health Care to Inmates
Since FY 2000, the BOP has implemented or developed at least
20 initiatives designed to improve the administration, management, and
delivery of health care to inmates, and to reduce or contain rising health
care costs. As of December 2007, the BOP had fully implemented 11
initiatives, while the remaining 9 were in progress. The following sections
summarize 10 of the BOP’s initiatives and discuss their cost impact.
Appendix II contains a complete list of the initiatives identified by the BOP
and a brief description of each initiative.
Medical Designations Program
BOP officials assign each inmate a medical classification or care level
based on the inmate’s individual health condition. Care levels range from
Care Level 1 for the healthiest inmates to Care Level 4 for inmates with the
most serious medical conditions.
•

Care Level 1 inmates are less than 70 years old and are generally
healthy but may have limited medical needs that can be easily
managed by clinician evaluations every 6 months. Sub-specialty
care is limited in that it is not regularly required and is completed in
less than 3 months. This care level includes inmates with stable
mental-health conditions requiring chronic care appointments and
individual psychology or health services contacts no more than once
every 6 months. The acute services required, such as crisis
15

intervention, are less than 3 months duration, occur no more than
every 2 years, and can be resolved without hospitalization.
•

Care Level 2 inmates are stable outpatients with chronic illnesses
requiring at least quarterly clinician evaluations. These inmates
independently perform daily living activities. The care level includes
inmates with mental health conditions that can be managed
through chronic care clinics or individual psychology or health
services contacts no more frequently than monthly to quarterly.
The acute services required, such as crisis intervention, are less
than 3 months duration, occur no more than every 2 years, and can
be resolved without hospitalization.

•

Care Level 3 inmates are fragile outpatients with medical
conditions that require daily to monthly clinical contact. These
inmates may have chronic or recurrent mental illnesses or ongoing
cognitive impairments that require daily to monthly psychiatric
health services or psychology contacts to maintain outpatient
status. These inmates may also require assistance in performing
some activities of daily living, but do not require daily nursing care.
Inmates in this care level may periodically require hospitalization to
stabilize the inmate’s medical or mental health condition.

•

Care Level 4 inmates have acute medical or chronic mental health
conditions resulting in severe impairments to physical and cognitive
functioning. These inmates require services at Medical Referral
Centers (MRC), such as the BOP’s Federal Medical Centers (FMC),
and may require varying degrees of nursing care.

In addition to assigning each inmate a care level based on overall
health, effective in 2004 the BOP also assigned a medical designation to
each institution. The medical designation corresponds with the medical
classification of the inmates that the institution is staffed and equipped to
handle. Appendix V shows the care level designation for each BOP
institution. Designating institution care levels has three advantages for the
BOP. First, it allows the BOP to establish guidelines for the number and mix
of medical staff to assign to each facility consistent with the care level
population at each facility. Second, it allows the BOP to evaluate every
inmate for appropriateness of placement and to initiate movement of
inappropriately housed inmates through routine transfers rather than waiting
until the inmate experiences a crisis requiring direct air or ground
transportation at a higher cost. Third, it allows the BOP to consolidate
inmates with similar medical conditions at facilities where appropriate
services and providers are available.

To coordinate its placement of inmates in institutions commensurate
with their care levels, the BOP developed the following phased
implementation plan.
•

Phase I – classify individual inmates as Care Level 1, 2, 3, or 4.

•

Phase II – designate institutions as Care Level 1, 2, 3, or 4, and
establish beds and staffing at each institution.

•

Phase III – realign health care staff as needed.

•

Phase IV – final implementation to include movement of inmates to
the appropriate care level institutions.

As of October 1, 2007, the BOP was in Phase IV of the implementation
plan. According to a BOP management official, all Care Level 3 inmates who
could be moved from Care Level 1 facilities had been moved. Some inmates
could not be moved for custody reasons, such as an inmate that must be
housed in a maximum security facility. According to this BOP official, such
exceptions were rare. As of June 2007, the BOP was in the process of
identifying and prioritizing the movement of Care Level 3 inmates out of
Care Level 2 facilities. According to the BOP official, approximately 1,200
Care Level 3 inmates remained to be moved. The BOP plans to complete
Phase IV by December 2008.
Medical Staff Restructuring
During FY 2005, the BOP established staffing guidelines for Care Level
1, 2, and 3 institutions. Since the existing staffing of the institutions did not
always match the care level staffing guidelines, the BOP had to move
medical staff throughout the BOP to implement the guidelines. Institutions
that had staff in positions contrary to the guidelines were required to either
move the staff to another facility that needed them or reassign the staff to
another authorized position in the facility. According to a BOP management
official, this process resulted in approximately 144 staff members in the
Health Services Units throughout the BOP being transferred to another
facility or reassigned to another position. This process also freed up a
number of positions that were returned to the BOP’s Health Services Division
and subsequently redistributed to institutions that were understaffed.

Tele-medicine
Tele-medicine involves the remote delivery of health care using
telecommunications technologies. For example, a psychiatrist may provide
psychiatric services via video conferencing equipment to inmates throughout
the BOP. From September 1996 to December 1997, the BOP participated in
a demonstration project to test the use of tele-medicine in three of its
institutions. Based on the success of the demonstration project, during
FY 2000, the BOP purchased videoconferencing equipment for every facility.
Since that time the BOP has purchased videoconferencing equipment for
each new institution. The BOP primarily uses tele-medicine to provide
psychiatry and radiology services. A BOP management official told us that in
the future the BOP plans to expand the use of tele-medicine to other
disciplines, including orthopedics, wound care, physical therapy, social
services, nutritional counseling, psychology, dentistry, cardiology,
dermatology, podiatry, obstetrics and gynecology, and oncology. As of
September 2007, the BOP had not developed a specific schedule for the
expansion. The BOP believes that tele-medicine can make medical services
more readily available while also containing and even reducing medical
costs.
Electronic Medical Records
Through automation of inmate medical records, the BOP expects to
reduce the paper records being produced, decrease the number of lost
records, diminish the need to fax records from place to place, and improve
the review and analysis of medical data. In March 2006, the BOP began
actively using its Bureau Electronic Medical Record (BEMR) system. The
initial BEMR system included the capability to: (1) track comprehensive
medical history and physical examination information, (2) schedule inmate
medical visits when required, and (3) record medical-related supplies and
equipment issued to inmates. The BOP subsequently added a pharmacy
module to the system (BEMRx) to manage the medications provided to
inmates.
As of October 30, 2007, the BOP had deployed the BEMR system to 63
institutions, of which 24 included the BEMRx pharmacy module. The BOP
plans to deploy the electronic medical records system to the rest of its
facilities by September 30, 2008. The BOP also plans that the completed

BEMR electronic medical records system will include access to the teleradiology archive and the Laboratory Information System.20
Medical Claims Adjudication
The BOP developed an initiative to target medical claims adjudication
to ensure that medical claims are properly paid and that the BOP complies
with the requirements of the Prompt Payment Act. Past OIG audits of BOP
medical contracts identified systemic contract-administration deficiencies
and erroneous contractor billings. In response to those findings, in
April 2004 the BOP began researching the use of third-party medical claims
processing services. In October 2004, the BOP received a presentation by
the Department of Veterans Affairs (VA) regarding the medical claims
processing services it provides to other government agencies. From
February 2005 to December 2005, the VA’s Financial Services Center
demonstrated the viability of the VA services in adjudicating (“testing”) the
accuracy of medical payment vouchers previously paid at nine BOP
institutions. The VA’s Financial Services Center determined that the BOP
had overpaid as much as $325,000 for the payments tested.
After the VA test, the BOP developed a Statement of Work defining
requirements for medical claims adjudication services. In July 2006, the
BOP issued a Request for Information asking interested vendors to submit
information about the medical claims processing services they could provide
for the BOP. The vendor responses indicated that the services sought are
readily available and can be acquired through contracting actions. Beginning
in July 2006, the BOP refined its requirements and finalized the Statement of
Work in September 2007. The BOP expects to award a contract for medical
claims adjudication services early in calendar year 2008.
Medical Reference Laboratory
Medical Reference Laboratories (MRL) perform laboratory tests of
patient specimens. A doctor or nurse usually collects the specimen and
sends it to the MRL for testing. The MRL then performs the requested tests
on the specimen and returns the test results to the requestor. In 2001, the
BOP established a mandatory MRL system at the following federal medical
centers:

The tele-radiology archive stores digital radiographic images and associated
interpretations without the risk of damage or loss applicable to film-based radiographs. The
Laboratory Information System stores laboratory test results which can be retrieved by BOP
personnel much quicker and easier than having the results mailed or faxed to them.

•

United States Medical Center for Federal Prisoners, Springfield,
Illinois;

•

Federal Medical Center, Rochester, Minnesota; and

•

Federal Medical Center, Butner, North Carolina.

This initiative was designed to contain or reduce health care costs by
having medical staff at non-medical center institutions collect and ship
specimens to one of the three MRLs where the laboratory tests could be
performed by BOP staff at a lower cost than through individual contracts for
laboratory services at each BOP institution.
Medical Equipment
The BOP also implemented an initiative in 1997 requiring that a senior
official at BOP headquarters approve all purchases of medical equipment
with a single item value of more than $1,000. The BOP subsequently raised
the approval threshold to $5,000. To obtain approval, the requesting
institution must submit a Major Equipment Justification and include evidence
that the institution researched alternatives to find the best value for the
equipment being acquired. This helps ensure that BOP institutions are not
frivolous with equipment requests and spending. Under the initiative, the
BOP also consolidates like purchases submitted for approval, which permits
better pricing on bulk purchases through one of the Department of Defense’s
Defense Supply Centers. The Defense Supply Centers primarily purchase
items such as food, clothing and textiles, pharmaceuticals, medical supplies,
construction items, and other equipment to support the U.S. military. The
centers also use their purchasing power to obtain such items for other
federal agencies at a lower cost.
Inmate Co-payment
In October 2005, the BOP began requiring inmates to pay a $2 copayment fee for certain types of medical evaluations. The BOP does not
charge indigent inmates a co-payment fee. The BOP also does not charge
inmates for certain medical services such as visits related to a chronic
medical condition, preventive health visits, or evaluations related to
pregnancy. The BOP designed the initiative to reduce the number of
unnecessary inmate-initiated medical visits. A BOP analysis of data for the
first 6 months of implementation showed a 33-percent reduction in the
number of inmate-initiated medical visits as compared to the 6-month period
prior to implementation.

Medical Coverage
Prior to January 2005, the BOP required 24-hour on-site medical
coverage at all institutions. In January 2005, the BOP discontinued the
requirement and instead required each institution to have a plan in place for
providing emergency and urgent care services when needed. According to
BOP Program Statement P6031.01 Patient Care, the plan should include a
team of first responders trained to use the automatic external defibrillator
and perform cardiopulmonary resuscitation. According to a BOP
management official, this change allowed institutions to reassign staff to the
day shift when inmates require the most medical care. This BOP official said
that the reduction in premium pay for the overnight periods resulted in
significantly reduced staffing costs.
Staffing Provider Teams
The BOP traditionally provided health care to inmates based on a
“military” model using the concept of sick call and same day treatment.
Under this concept, inmates were evaluated by an available provider that
day. According to BOP officials, this led to inmates “practitioner shopping”
where they would go from provider to provider for treatment of the same
complaints. In 2005, the BOP began implementing the Patient Care Provider
Team concept where inmates are assigned to a primary provider team that
manages both the chronic and episodic care of the inmate. The BOP
designed this approach to improve the consistency of treatment and
eliminate the ability of the inmate to consume valuable staff resources by
practitioner shopping. According to a BOP management official,
implementation of this concept has reduced duplicate diagnostic tests,
consultations, and treatments, thereby reducing overall medical costs.
Cost Impact of the BOP’s Health Care Initiatives
One of the primary purposes of the BOP’s health care initiatives was to
reduce or contain health care costs. However, the BOP could not provide us
with cost benefit analyses for its 20 health care initiatives. Therefore, we
were unable to assess the cost benefits of BOP initiatives on an individual
basis. We were, however, able to analyze the BOP’s overall inmate medical
costs during our review period.
Efforts to Measure Cost Benefits of BOP Health Care Initiatives
For the 20 health care initiatives listed in Appendix II, we asked BOP
officials for any cost-benefit analyses to justify implementation of the
initiatives and any post-implementation analyses to determine their cost
21

impact. Although the initiatives usually had a primary or secondary purpose
of reducing or containing health care costs, the BOP could not provide
documentation of any preliminary cost-benefit analyses or any postimplementation analyses to identify costs reduced or contained.
BOP management officials believed that preliminary cost-benefit
analyses had been performed for many of the initiatives, but the analyses
would have been done by BOP staff previously responsible for the initiatives
and the documentation of the analyses was no longer available. As for
post-implementation analyses, BOP management officials told us that the
BOP does not collect and maintain cost-related data that would allow it to
analyze the cost-effectiveness of its individual health care initiatives.
While we are encouraged by the BOP’s efforts to develop new
initiatives to improve health care for inmates and to reduce and contain
health care costs, we believe the BOP should collect cost-related data for
each initiative and analyze the collected data to determine whether the
initiatives are providing the anticipated cost benefits. Without such
analyses, the BOP may expend funds on initiatives that are not costeffective.
Cost Impact of the BOP’s Health Care Initiatives
Absent cost data for individual health care initiatives, we analyzed the
overall effect of the BOP’s initiatives on total medical costs. For calendar
years (CY) 2000 through 2006, we compared the BOP’s per capita health
care costs to the national average per capita cost for medical expenses as
reported by the Department of Health and Human Services' (HHS) National
Health Statistics Group and to the Consumer Price Index (CPI) for Medical
Care published by the Department of Labor’s (DOL) Bureau of Labor
Statistics. As shown in the following graph, we found that although the BOP
experienced growth in health care costs in excess of the HHS national
average and DOL CPI for some of the earlier years of our review period, the
BOP’s growth rates since 2002 have declined significantly while the growth
rates in the HHS national average and the DOL CPI have not.

Comparison of the Growth Rates of Health Care Costs for BOP, HHS, and
DOL Health Care Data for Calendar Years 2000 through 200621
9%
8%

G
r
o
w
t
h
R
a
t
e

7%
6%
5%

BOP

HHS

DOL

2%
1%
0%
-1%

-2%

2000 - 2001 - 2002 - 2003 - 2004 - 2005 2001

2002

2003

2004

2005

2006

Calendar Years
Source: BOP Office of Research and Evaluation, BOP Budget Execution Branch,
Department of Health and Human Services, and Department of Labor

We recognize that the BOP’s, HHS’s, and DOL’s per capita health care
medical costs are not exactly comparable. The BOP’s medical per capita
costs include costs for services not included in the HHS’s and the DOL’s per
capita medical costs and vice versa. For instance, the BOP’s medical per
capita costs include costs for medical guard escort services, airlift
expenditures, and costs for replacement equipment, while the HHS’s and the
DOL’s per capita medical costs do not include these items. In contrast, the
HHS’s and the DOL’s medical per capita costs include cost for health
insurance, home health care, and over-the-counter drugs, while the BOP’s
per capita medical costs do not include these items. Even though the costs
are not fully comparable between the three measures, we believe the cost
measures are sufficiently similar for comparison purposes and show that the
BOP appears to be controlling the growth in health care costs.

Providing Medical Services to Inmates
In addition to analyzing the BOP’s efforts to contain health care costs,
we also evaluated whether the BOP was providing inmates with expected
preventive medical services. Both our audit testing and reviews by the
BOP’s Program Review Division found that BOP institutions do not always
provide expected preventive medical services to inmates.
OIG Testing
As discussed in the Introduction, the BOP established 16 Clinical
Practice Guidelines providing guidance to its institutions concerning health
care services for inmates. The BOP Medical Director considered the
guidelines to be “best medical practices” and told us that while the
guidelines have not been incorporated into the BOP’s program statements as
policy, he expects BOP institutions to provide these services to inmates.22
The Medical Director also informed us that institutions have discretion to
depart from the guidelines on a case-by-case basis. However, institutions
must request and receive approval from the Medical Director to not
implement a specific guideline requirement.
To determine whether institutions were providing these medical
services to inmates, we selected and tested services listed in the BOP’s
Preventive Health Care Clinical Practice Guideline. We chose this particular
BOP guideline because:
•

It addressed care for all inmates, instead of only inmates with
specific illnesses;

•

It included diagnostic procedures for 9 of the 11 chronic conditions
addressed in the other 15 guidelines;

•

It contained clearly defined medical services that could be
reasonably tested;

•

Health promotion and disease prevention is a primary objective of
the BOP’s efforts to contain costs; and

•

The BOP Medical Director told us that our testing of the preventive
health care guideline would provide useful information to the BOP

The BOP publishes its mandatory policies and procedures in program statements.
The BOP also publishes clinical practice guidelines that contain specific procedures and tests
that the BOP expects its providers to follow when providing medical care to inmates.

because its per capita cost of providing health care should be
reduced by implementing a good preventive health program, and
he expects the institutions to provide the services in the guideline.
We identified 30 specific preventive health care services in the BOP’s
Preventive Health Care Clinical Practice Guideline with clearly defined
requirements that allowed for testing whether the services were provided.
Appendix III shows the 30 services we tested, which included whether:
(1) inmates received a measles, mumps, and rubella vaccine, (2) inmates
received a hepatitis A vaccine, (3) inmates received a cholesterol check in
the last 5 years, (4) female inmates received a chlamydia test, and
(5) female inmates received a bone density screening test.
To perform our testing of the 30 medical services, we selected a
sample of 1,110 of the 14,026 inmates assigned to 5 BOP facilities as of
March 24, 2007, as shown in the table below. Appendix IV contains an
explanation of our sampling methodology.
Inmate Population and Inmates Sampled

BOP Facility
USP Atlanta (Georgia)
USP Lee (Virginia)
Federal Correctional Complex Terra Haute (Indiana)
Federal Medical Center Carswell (Texas)
Federal Correctional Complex Victorville (California)
Totals
Source: OIG sample from BOP inmate population data

Inmate Population
as of
March 24, 2007
2,494
1,808
3,343
1,677
4,704
14,026

Inmates
Sampled
251
133
249
127
350
1,110

For each inmate sampled, we reviewed the inmate’s medical record
and determined whether the inmate received the 30 preventive services, as
applicable. The 30 services were not applicable to all inmates sampled
because certain services applied only to female inmates, the services applied
only to inmates over a certain age, and the services applied only if the
inmate had certain risk factors. To validate our testing, we asked a Health
Services Unit official at each of the facilities tested to confirm our results and
ensure that we had not overlooked the provision of any service.
As shown in the following two charts, the combined results for all
5 locations showed that, for 16 of the 30 services tested, 90 percent or more
of the inmates received the preventive service as appropriate. For the
remaining 14 services, more than 10 percent of the sampled inmates did not

receive the medical service.23 For example, 94 percent of the inmates who
should have received a cardiovascular risk calculation had not received one
in the last 5 years as required by BOP policy. Additionally, 87 percent of the
sampled inmates needing a measles, mumps, and rubella vaccine had not
received this service.
Overall Results of the OIG’s Testing of
Medical Services Provided to Inmates24

Medical Service Tested

Yes

Inmates
Tested

1. Inmate medical history
provided by inmate at intake

1,044

99%

2. Medical assessment completed
by medical practitioner at intake

1,044

99%

3. New inmate tested for
tuberculosis or previous test for
transferred inmate confirmed,
within 48 hours of intake

1,043

99%

4. Inmate received rapid plasma
regain test during intake screening
to test for syphilis
5. Female inmate tested for
chlamydia

6. Female inmate received a
measles/mumps/rubella vaccine

128

7. Inmate received a complete
physical within 14 days of intake

1,044

8. Inmate received a
pneumococcal vaccine

9. Inmate received an annual
influenza vaccine

210

10. Inmate born after 1956 received
a measles/ mumps/rubella vaccine

932

11. Inmate received a tetanus
vaccine in the last 10 years

92%

403

36%

64%
81%

19%

95%

4%
23%

74%
71%
13%

29%
87%
49%

50%

1,042

12. Inmate received a hepatitis A
vaccine

263

13. Inmate received a hepatitis B
test or vaccine

343

90%

14. Inmate received a hepatitis C
test

267

91%

57%

42%

The percentages in the chart are based on the number of inmates for whom the
service was applicable.
24

Some percentages in the chart total less than 100 percent because
documentation was not available to determine if the test was performed for some inmates.

Medical Service Tested

Inmates
Tested

Yes

15. Inmate received an HIV-1 test

381

16. Inmate received an HIV-2 test

130

98%

17. Inmate received a tuberculosis
test in the past year

869

98%

18. Inmate received a chronic care
evaluation in the last 6 months

339

19. Inmate received a cholesterol
check in the last 5 years

678

20. Inmate received a cardiovascular
402
risk calculation in the last 5 years

93%

98%

94%
84%

1,043

23. Inmate received a current
body mass index calculation

1,036 12%

26. Inmate received a hearing
screening test

27. Inmate received an
abdominal ultrasound test

28. Female inmate received a
papanicolaou test (PAP smear)

30. Female inmate received a
bone density screening test

88%
54%

46%

93%
51%

49%
100%
99%

142

29. Female inmate received a
current mammogram

12%

96%

189
58

29%

22. Inmate received a current
blood pressure check

25. Inmate received a vision
screening test

71%

21. Inmate received a fasting plasma
324
glucose test in the last 3 years

24. Inmate received a fecal
occult blood test

100%
38%

62%

Source: OIG testing of BOP medical records

We could not determine if some services were provided because
information was either not recorded or was missing from the inmates’ medical
records. Appendix VII contains our test results at each of the five BOP
facilities. For each BOP location tested, the following chart presents the
percentages of inmates not receiving a calculation for cardiovascular risk. As
the chart shows, inmates at all five facilities rarely received this service.

Percent of Applicable Inmates not Receiving a
Current Cardiovascular Risk Calculation
Inmates
Tested
82

100%

98%

FMC Carswell

98%

USP Lee

USP Atlanta

FCC Terre Haute

82%

131

FCC Victorville

98%
100

Percent

Source: OIG testing of BOP medical records

Medical staff at three of the five institutions told us that they usually
did not perform this service because they considered the service
unnecessary or they use an alternate method to evaluate the inmate for this
condition. Medical staff at another institution told us they did not perform
this service because of staffing inadequacies and scheduling constraints.
Officials at the other institution, FMC Carswell, declined to provide us with an
explanation for not performing these services, stating that BOP headquarters
would respond to the finding after we issued our report.
We also found a large inconsistency among the institutions in providing
other medical services. For example, as shown in the chart below, we found
that the percentage of applicable inmates not receiving a cholesterol check
within the past 5 years ranged from 68 percent at USP Lee to 8 percent at
FMC Carswell. This disparity indicates a need for better BOP headquarters
oversight and guidance of the extent to which institutions implement
expected services.
Percent of Applicable Inmates not
Receiving a Cholesterol Check in Last 5 Years
Inmates
Tested
135

USP Atlanta

29%

8% FMC Carswell

72
68%

USP Lee

187

13% FCC Terre Haute

215

FCC Victorville

36%
100

50
Percent

Source: OIG testing of BOP medical records

In another example, as shown in the following chart, we found that the
percentage of applicable inmates not receiving a tetanus vaccine in the past
10 years ranged from 72 percent at USP Lee to 5 percent at USP Atlanta.
Percent of Applicable Inmates not
Receiving a Tetanus Vaccine within Past 10 Years
Inmates
Tested
191

5% USP Atlanta

127

FMC Carswell

19%

133

72%

248

USP Lee
FCC Terre Haute

60%

345

FCC Victorville

68%
100

50
Percent

Source: OIG testing of BOP medical records

Additional inconsistencies between the five institutions can be seen by
reviewing our results in Appendix VII. These include large inconsistencies
among the institutions in performing tests for chlamydia, hepatitis C, HIV,
vision, and hearing; and providing vaccines for pneumonia; influenza; and
measles, mumps, and rubella.
We asked officials at each of the five institutions for an explanation of
why some services were not provided to a significant number of inmates.
The explanations provided by institution officials are discussed below.
USP Atlanta. USP Atlanta officials did not give us an explanation for
why inmates were not provided a cholesterol test and a fasting glucose test,
but gave the following explanations for not supplying other medical services
to inmates.
•

Influenza vaccine – Officials told us that the vaccine was not always
available.

•

Measles, Mumps, and Rubella vaccine – Officials said they believed
that the requirement only applied to women.

•

Cardiovascular risk calculation – Officials told us that they used
alternative methods for determining cardiovascular risk.

•

Body Mass Index calculation – Officials said they considered this
calculation unnecessary.
29

•

Fecal Occult Blood test – Officials told us that the inmates share the
responsibility for completion of this test and that generally the
inmates fail to return the test cards.

•

Hearing Screening – Officials said that there was no occupational
risk at the institution, and they overlooked the requirement for
screening inmates age 65 and over.

Health Services Unit management officials at USP Atlanta said they
viewed the Preventive Health Care Clinical Practice Guideline as a
recommended, but not mandatory, regimen of health care practices and had
identified certain tests or procedures that they did not consider necessary
and therefore did not perform routinely. The USP Atlanta had not requested
and received a waiver from the BOP Health Services Division to deviate from
any of the guidelines.
USP Atlanta had not yet implemented BOP’s Primary Care Provider
Teams (PCPT), and this may have contributed to expected medical services
not being provided. Under the PCPT model, each inmate is assigned to a
medical team of health care providers and support staff who are responsible
for managing the inmate’s health care needs. The PCPT model is designed
to provide inmates with better and more consistent medical care because
the inmate is examined by the same provider team each time the inmate
requires medical attention. The inmate should be less likely to miss some
services because the provider team would be familiar with the services
previously provided the inmate. According to the BOP’s Preventive Health
Care Clinical Practice Guideline, the most efficient and cost-effective way to
implement the guideline is to assign appropriate responsibilities to each
PCPT member. However, USP Atlanta officials told us that as a result of
limited staffing they have been unable to establish the Primary Care Provider
Teams.
After we performed audit tests at USP Atlanta, we met with the BOP’s
Medical Director and other management officials from the BOP’s Health
Services Division to clarify the BOP’s expectations for institutional
compliance with the Preventive Health Care Clinical Practice Guideline. BOP
management officials told us that because of frequent changes in the
guidelines and the lengthy process to change or update BOP policy in its
program statements, they did not incorporate the clinical practice guidelines
into the BOP’s program statements. However, the Medical Director told us
that he considers the clinical practice guidelines to be “best medical
practices” and he expects the institutions to follow the guidelines when
providing medical care to inmates. The Medical Director said that institution
officials could use discretion and professional judgment when determining
30

whether to follow the guidelines on a case-by-case basis. However, the
Medical Director told us that if institution officials decide not to follow a
guideline on an institution-wide basis, then the institution officials must
request and receive his approval to do so. The USP Atlanta had not done so.
USP Lee. USP Lee medical officials told us that they did not provide
routine tests and vaccines because of the cost of the procedures and the
overall good health of USP Lee’s Care Level 1 population. USP Lee officials
said that they rely heavily on the inmates’ responsibility for improving their
health and seeking preventive health care. As was the case at USP Atlanta,
medical officials at USP Lee also had not fully implemented the PCPT and did
not use the Preventive Health Care Model. Medical personnel at USP Lee
told us that they had not fully implemented the PCPT because USP Lee was a
Care Level 1 facility and its staff was limited.
FCC Terre Haute. FCC Terre Haute medical officials told us that they
did not provide routine tests and vaccines because of staffing inadequacies
and scheduling constraints. The medical officials at FCC Terre Haute also
had not fully implemented the PCPT because of staffing shortages and did
not use the Preventive Health Care Model.
FMC Carswell. FMC Carswell medical officials declined our requests
for an explanation of why certain services were not provided to inmates.
The officials said that BOP headquarters would provide a response after we
issued our report. Medical officials at FMC Carswell had implemented PCPT.
Officials told us while staff members and inmates were assigned to provider
teams, nurses had to assist on multiple teams because of the limited
number of nurses on staff. As a result of our audit, staff at FMC Carswell
identified areas for improvement, such as providing a chlamydia test to all
females who were under 25 years of age. This institution began providing
the chlamydia test in accordance with the Clinical Practice Guideline
immediately following our site visit.
FCC Victorville. FCC Victorville medical officials told us that they did
not provide routine tests and vaccines because it was too costly due to its
large inmate population. For instance, because of the high cost for vaccines,
FCC Victorville generally provided vaccines such as tetanus to inmates with
open injuries rather than every 10 years as required by the guideline.
Medical officials at FCC Victorville also had not fully implemented the PCPT.
Medical staff had assigned inmates to a mid-level practitioner, but staffing of
provider teams was not complete. As a result of our audit, staff at Victorville
began implementing additional practices, such as bone density screening for
female inmates, in accordance with the Preventive Health Clinical Practice
Guideline.
31

Testing by the BOP’s Program Review Division
The BOP’s Program Review Division also has identified instances where
institutions did not provide required medical services to inmates. The
Program Review Division performs reviews at BOP institutions, generally on
a 3-year cycle, to determine whether the institutions are in compliance with
a variety of BOP policies. As part of these reviews, the teams determine
whether the institution provided certain required medical services to
inmates.
From FYs 2004 through 2006, the BOP’s Program Review Division
conducted 110 reviews at 88 locations. Of the 110 reviews, 40 reviews (36
percent) identified a total of 25 required medical services that institutions
did not always provide to inmates. The following table shows the number of
institutions that did not provide certain services.

Medical Service not Provided
Inmates with chronic care conditions
were not monitored as required.
2. Some inmates were not monitored for
psychotropic medical side effects.
3. The Hepatitis-B vaccine was not
offered to inmates in a high-risk
work detail.
4. Inmates did not receive adequate
dental screening.
5. Inmates did not receive a
gynecological examination.
6. HIV positive inmates did not receive
counseling.
7. Inmates admitted at a local hospital
were not adequately monitored by a
medical doctor.
8. Inmates did not receive a timely intake
physical.
9. HIV positive inmates did not receive
recommended vaccine.
10. Inmates did not receive a baseline
liver function test before isoniazid
treatment.

Number of
Institutions Where
Problem Found

16
11
8
7
6
5
5
3
3
2

Medical Service not Provided
11. Inmate physicals were missing vital
signs.
12. Inmates taking TB medications were
not monitored for side effects.
13. Tests ordered by physicians were not
completed.
14. Isoniazid treatment for latent
tuberculosis was not extended when
treatment was missed.

Number of
Institutions Where
Problem Found
2
2
2
2

Source: OIG analysis of BOP program review reports

Potential Effect of Not Providing Services
For a variety of reasons, inmates should be provided the medical
services that BOP policies require or that BOP management expects. If
expected medical services are not provided, an inmate’s medical condition
may worsen and the BOP may be faced with much higher medical treatment
costs for an extended period of time.
During FYs 2004 through 2006, the BOP received 12,960 medicalrelated complaints. The BOP granted relief for 1,970 of these complaints.
Over the same period, 6,030 medical-related complaints were appealed to
the BOP’s regional offices and 2,987 complaints were appealed to BOP
headquarters. The BOP granted relief for 202 and 9 of these complaints,
respectively.
For the same 3-year period, decisions were made on 233 medicalrelated lawsuits and appeals against the BOP. Of the 233 lawsuits and
appeals, 221 were dismissed, 1 was decided favorably for the BOP, and 11
were settled out of court for a total of $2,036,790. The 11 settlements
involved 3 claims of wrongful deaths and 8 claims of inadequate, improper,
or negligent medical care. In a recent case, an inmate died 6 days after his
first chronic care visit to a BOP medical provider. The BOP’s mortality review
for this case indicated that the inmate did not receive appropriate medical
care during his incarceration. Specifically, upon intake at the facility on
November 27, 2006, the inmate was referred to the chronic care clinic based
on a history of severe scoliosis and chronic low back pain. However, the
inmate was not seen in the chronic care clinic until 5 months later on
April 27, 2007. A follow-up Electrocardiogram (EKG) was performed on
May 1, 2007, and noted to be abnormal. However, the EKG results were not
reviewed by a medical doctor until May 3, 2007, the day the inmate died of
a heart attack.
33

Conclusion
The BOP has implemented numerous health care initiatives aimed at
reducing or containing health care costs. We were able to evaluate the
BOP’s overall health care costs, and we found that the BOP has done well in
effectively controlling the overall rate of increase in its per capita health care
costs, particularly when compared to national health care cost data reported
by the Departments of Health and Human Services and Labor. However, the
BOP did not maintain cost data to measure the effect of its individual
initiatives on specific and overall medical service costs. Therefore, we could
not determine the cost effectiveness of BOP health care initiatives on an
individual basis. We recommend that the BOP begin collecting and analyzing
cost data for its medical services to determine the effectiveness of each of
its initiatives in controlling and reducing the costs of specific medical services
and overall inmate health care. Without such analysis, the BOP cannot
determine which initiatives are most effective and which are not producing
desired results.
Additionally, we found that BOP institutions did not always provide
inmates with the medical services expected by BOP management and
identified in BOP guidance. Our review, as well as evaluations performed by
the BOP’s Program Review Division, identified medical services that BOP
institutions did not always provide to inmates. The BOP Medical Director
stated that he expects the institutions to provide these medical services to
inmates.
The failure to correct these deficiencies could lead to higher costs for
providing health care, decreases in the quality of health care provided,
exacerbation of inmate medical conditions, medical-related complaints and
lawsuits from inmates, and BOP liability for lack of adequate medical care.
We recommend that the BOP review the required medical services that
the OIG and the BOP’s Program Review Division determined were not
provided consistently to inmates and decide whether the BOP still considers
these services necessary. If the BOP deems any of the services
unnecessary, it should remove them from the guidelines that recommend
the services be provided. For services that the BOP determines are
necessary, the BOP should develop a mechanism to ensure its institutions
are consistently complying with BOP policy concerning these medical
services.

Recommendations
We recommend that the BOP:
1.

Establish procedures for collecting and evaluating data for each current
and future health care initiative to assess whether individual initiatives
are cost-effective and producing the desired results.

Review the medical services that the OIG and the BOP’s Program
Review Division identified as not always provided to inmates and
determine whether those medical services are necessary, or whether
the medical service requirement should be removed from the clinical
practice guidelines.

Issue clarifying guidance to the institutions regarding the medical
services that BOP decides are necessary for BOP medical providers to
perform.

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2. BOP CONTRACT ADMINISTRATION
Prior OIG audits of BOP medical contracts have identified
multiple contract-administration deficiencies, such as inadequate
review and verification of contractor invoices and inadequate
supporting documentation for billings. Several of these
deficiencies appeared to be systemic. The deficiencies primarily
resulted from inadequate or non-existent guidance or procedures
regarding critical management controls over these contracts.
After these previous audits, the BOP took action to address
individual deficiencies at the institutions we audited. However,
in this audit we found that other BOP institutions lacked
appropriate controls in the same areas identified by our prior
contract audits, which indicates the existence of systemic
weaknesses that are not being adequately addressed by the
BOP.
From August 2004 through March 2007, the OIG issued the following
nine audit reports on BOP medical contracts. Appendix X contains
summaries of these audits.
OIG Audits of BOP Medical Contracts
August 2004 through March 2007

Report Title and Number
The Bureau of Prisons’ Contract with the Parkview
Medical Center for the Acquisition of Medical
Services (J40604c-030),
Audit Report GR-60-04-008
Correctional Medical Services’ Compliance with the
Federal Bureau of Prisons’ Contract J21451c-009,
Audit Report GR-70-04-009
The Federal Bureau of Prisons’ Contract with Medical
Development International for the Acquisition of
Medical Services at its Leavenworth, Kansas
Facilities (Contract No. DJB40804003),
Audit Report GR-60-05-003
The Federal Bureau of Prisons’ Medical Services
Contract with Wayne Memorial Hospital, Jesup,
Georgia (Contract J30703c-020),
Audit Report GR-40-05-006
The Federal Bureau of Prisons’ Contract Number
DJB21602-004 with Salem Community Hospital in
Salem, Ohio, Audit Report GR-50-05-012

Institution

Month and
Year Issued

FCI Florence

August
2004

FCI Fort Dix

September
2004

USP Leavenworth

February
2005

FCI Jesup

April
2005

FCI Elkton

June
2005

Report Title and Number
The Federal Bureau of Prisons’ Medical Services
Contract with Hospital Corporation of America HealthONE, L.L.C., Contract No. J40303c-146,
Audit Report GR-60-06-006
The University of Massachusetts Medical School and
UMass Memorial Health Care, Incorporated’s
Compliance with the Federal Bureau of Prisons’
Contract DJB20507032,
Audit Report GR-70-06-006
The Federal Bureau of Prisons’ Medical Services
Contract with John C. Lincoln Health Network
Contract No. DJB60803144,
Audit Report GR-60-06-009
The Bureau of Prisons’ Management of the Medical
Services Contract with Medical Development
International, Butner, North Carolina, Contract No.
DJB10611-00, Audit Report GR-40-07-003

Institution

Month and
Year Issued

FCI Englewood

March 2006

FMC Devens

March 2006

FCI Phoenix

August 2006

FCC Butner

March 2007

Source: OIG Audit Reports

Eight of the nine OIG contract audits identified major internal control
deficiencies. The deficiencies included management control weaknesses
pertaining to calculating medical service discounts, reviewing and verifying
invoices and billings, paying bills, and managing the overall administration of
the contracts. Based on the results of these audits, the following
weaknesses appeared to be systemic.
•

Six of the contract audits found weaknesses in verifying and
reviewing the accuracy of invoices for medical services provided by
the contract providers.

•

Five of the contract audits found weaknesses in obtaining
supporting documentation for contractor billings.

•

Four of the contract audits found errors in the Medicare or
diagnostic-related groups discount rates.

•

The OIG contract audits identified about $12.3 million in questionable
payments to the contractors. The audits usually found that the identified

weaknesses were attributable to the lack of written procedures and other
internal controls.
As of November 2007, the BOP’s Program Review Division said that
corrective actions had been implemented for all recommendations in seven
of the nine contract audits. For the other two audits, the BOP agreed to take
corrective actions on our recommendations, and those actions were either
completed or in progress as of November 2007.
In response to six of the nine audits, the BOP strengthened
management controls by establishing written procedures for processing and
monitoring contract medical claims. However, these actions were limited to
correcting the deficiencies only at the institutions where the deficiencies
were found. We found no indication that the corrective actions on the
systemic weaknesses found in these audits were shared with other BOP
institutions. Further, as discussed on page 19, in response to OIG findings
on BOP’s payment of medical claims, the BOP began an initiative in 2004
designed to ensure medical claims are properly paid. However, the BOP
does not expect to award a contract for medical claims adjudication services
until early in calendar year 2008. We found no indication that the BOP
issued any interim guidance agency-wide to address the problems the OIG
found with paying medical claims.
To address the OIG audit findings nationally, BOP officials told us that
the following actions have been taken.
•

The BOP’s Field Acquisition Office staff visit institutions about 2 to 3
months after the award of a comprehensive medical contract to
provide contract orientation, bill verification training, and a contract
administration briefing.

•

The BOP issued a memorandum to its regional directors and chief
executive officers in February 2005 to heighten awareness of
recurring findings in OIG audits. The BOP included a Contract
Administration Checklist with the memorandum, but stated that use
of the checklist was optional.

•

The BOP provided training to almost 200 BOP institution contracting
staff at Advanced Procurement Training classes that covered
comprehensive medical contracts, contract administration guidance,
and recurring findings in OIG audits.

As part of this larger audit of BOP medical services we tested other
BOP institutions for controls related to the deficiencies identified in our nine
39

individualized BOP contract audits. Internal control is a major part of
managing an organization. It includes the plans, methods, and procedures
used to meet missions, goals, and objectives and, in doing so, supports
performance-based management. Internal controls on all transactions and
other significant events need to be clearly documented, and the
documentation should be readily available for examination. The
documentation should appear in management directives, administrative
policies, or operating manuals and may be in paper or electronic form. In
addition, the documentation and records should be properly managed and
maintained.
We interviewed BOP officials at the five BOP institutions where we
conducted fieldwork during this audit and sent survey questionnaires to the
remaining 88 BOP institutions. Through the interviews and surveys we
inquired if BOP institutions had established internal control procedures for
their comprehensive medical services contracts, including:
•

reviewing contractor invoices for accuracy,

•

ensuring contractor invoices are supported by adequate
documentation,

•

ensuring that invoice discounts are properly applied,

•

ensuring that contractor performance reports are complete and
accurate, and

•

ensuring that contractor timesheets are verified by a BOP
employee.

If the institutions responded that procedures were established, we
asked whether the procedures were in writing. Despite the training
conducted and the guidance issued by the BOP, we found that up to seven
BOP institutions lacked critical controls for certain contract administration
functions. We also found that approximately half the institutions with critical
controls had not documented the procedures associated with the controls.
Our analysis of survey responses found that 77 of the 88 BOP institutions
surveyed had comprehensive medical service contracts. Generally, officials
at each institution responded that they had established internal control
procedures for administering their institution’s contracts. However, we
found that about half the institutions had not formalized these procedures in
written policy for the controls we tested, as noted in the chart below.

Controls Established by BOP Institutions for
Comprehensive Medical Services Contracts
Number of Institutions
Procedures
Established
Procedures
but not
Established
Written

Percent of
Established
Procedures
not Written

51%

49%

47%

57%

The lack of written procedures increases the risk that appropriate
controls will not be fully and consistently implemented, especially when staff
assignments and duties change. In the nine individual contract audits,
failure to effectively implement the five controls had multiple effects. For
example, in one audit of a major medical services contract, the OIG found
that the BOP did not adequately review contractor invoices for accuracy,
ensure contractor invoices were supported by documentation, and assure
contractor timesheets were verified by a BOP employee. As a result of these
weaknesses, the audit identified $2,428,345 in questioned costs related to:
•

instances in which invoices contained transactions that were not
within the billings’ service period;

•

transactions for which the contractor billed the BOP at a rate higher
than specified in the contract;

•

transactions in which the contractor billed the BOP for a
cardiologist’s reading of echocardiography results, which was not
covered by the contract;

•

transactions for timesheets that were either miscalculated,
overstated, understated, or unsupported;

•

transactions where the hours billed for contractor employees were
greater than the hours recorded in the institution’s contractor time
logs;

•

transactions where the hours billed were for contractor employees
whose names did not appear in the contractor time logs; and

•

inadequate support for billings for “on call” services provided under
the contract.

Similar weaknesses were noted in the other contract audits. In short,
if controls are not established, documented, and applied BOP-wide to
address these contract administration functions, the BOP could experience
similar negative effects on its medical contracts all across the BOP, such as
paying contractor invoices that contain unallowable or unsupported costs.
Conclusion
This audit, along with prior OIG audits of individual BOP medical
contracts, found that BOP institutions lacked adequate management controls
to ensure the effective administration of critical medical service contract
functions. The absence of such controls appears to stem from BOP
headquarters not identifying systemic weaknesses and implementing the
necessary policies and internal control procedures to remedy the issues. We
found in our individual BOP medical contract audits that the lack of
management controls resulted in the BOP making questionable payments to
contractors. In total, the OIG contract audits identified about $12.3 million
in questionable payments to the contractors. We believe our findings in this
review and in the individual audits on BOP medical contract administration
illustrate the likelihood that similar weaknesses exist in medical contracts in
other BOP institutions that we have not audited. We recommend that the
BOP strengthen controls by providing guidance and procedures to its
institutions to help ensure that systemic deficiencies are corrected
throughout the BOP.
Recommendation
We recommend that the BOP:
4.

Strengthen management controls to ensure proper administration of
BOP medical contracts by providing guidance and procedures to all BOP
institutions for:

•

reviewing contractor invoices for accuracy,

•

ensuring contractor invoices are supported by adequate
documentation,

•

ensuring that invoice discounts are properly applied,

•

ensuring that contractor performance reports are complete and
accurate, and

•

ensuring that contractor timesheets are verified by a BOP employee.

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3. MONITORING BOP HEALTH CARE PROVIDERS
The BOP monitors its health care providers by performing
program reviews of institution operations, reviewing medical
provider skills and qualifications and providing authorization
documents based on the review results, and requiring
institutions to accumulate and submit to BOP headquarters data
on health-related performance measures. However, while the
BOP corrected deficiencies at the specific institutions where its
program reviews found weaknesses, it did not develop and issue
guidance to correct systemic deficiencies found during the
reviews. Additionally, we determined that the BOP allowed some
health care providers to practice medicine without valid
authorizations. Also, health care providers did not have their
practices peer reviewed to ensure the quality of their medical
care as required by BOP policy. Moreover, while BOP institutions
accumulated and reported data on health-related performance
measures, the methods used to do so were inconsistent and the
data was not analyzed to evaluate the performance of BOP
institutions.
The BOP uses numerous mechanisms to monitor its health care
providers. Some of the mechanisms include:
•

conducting internal program reviews to determine whether each
institution is properly implementing BOP policies, including policies
related to inmate health care;

•

granting clinical privileges and establishing practice agreements and
protocols based on health care providers’ qualifications, knowledge,
skills, and experience;25

•

conducting peer reviews of health care providers to assess the
competency of the providers; and

•

requiring each institution to accumulate and report performance
data on a quarterly basis for specific health-related areas.

The primary purpose of these monitoring mechanisms is to help
ensure the quality and efficiency of health care delivered to inmates by
identifying and correcting deficiencies in the provision of health care, and in
25

Clinical privileges and practice agreements authorize the specific clinical or dental
duties that health care providers may provide to BOP inmates.

authorizing duties for health care providers commensurate with their skills
and capabilities.
The BOP’s Program Review Results
Program Statement P1210.23, Management Control and Program
Review Manual, requires that the BOP’s Program Review Division perform a
comprehensive review of each program or operation at each BOP institution
in accordance with published program review guidelines. The program
reviews are generally conducted once every 3 years, or more frequently if
the reviews identify overall performance that is less than a certain level.
Program Review Guideline G6000I.04, Health Services, provides the specific
review steps for the Program Review Division to complete when performing
a program review of the health services function at BOP institutions.
From FYs 2004 to 2006, the Program Review Division conducted
110 program reviews of health care at 88 BOP locations. We reviewed the
resulting reports and determined that the Program Review Division
consistently identified deficiencies related to inmate health care. As
discussed in Finding 1 of this report, 40 of the 110 reviews found medical
services deficiencies.
In response to these reviews, the Program Review Division required
institutions to certify completion of corrective actions addressing the
deficiencies it identified. The Program Review Division also prepared
quarterly program summary reports that identified the most frequent
deficiencies found during the program reviews. The Division provided the
summary reports to all BOP Chief Executive Officers, including the BOP
Health Services Division Medical Director. However, a senior Health Services
Division official told us that the BOP probably would not change policy when
program reviews find problems in a certain area, but it may provide training
to improve staff knowledge and compliance. The official said the Division
relies on the BOP Regional Offices and institutions to correct the problems.
We analyzed the 40 BOP reviews and found that 25 different medical
services were not provided to inmates and that 14 of the 25 deficiencies
were identified for multiple institutions. For example, as shown in the table
on page 32, the Program Review Division found inmates with chronic care
conditions that were not monitored at 16 BOP institutions as required by
BOP policy. Also, the reviews found inmates that were not monitored for
psychotropic medical side effects at 11 institutions.

We recommend that the BOP use the program summary reports to
develop or clarify guidance to correct systemic deficiencies identified during
the internal program reviews.
The BOP’s Credential Verification, Privileges, and Practice
Agreement Program
In providing inmate health care, BOP institutions employ or contract
for the following health care providers.
•

Licensed independent practitioners are medical providers
authorized by a current and valid state license to independently
practice medicine, dentistry, optometry, or podiatry.

•

Non-independent practitioners are graduate physician assistants
(certified or non-certified), dental assistants, dental hygienists,
nurse practitioners, and unlicensed medical graduates.

•

Other practitioners are those not included in the above categories
and include clinical nurses and emergency medical technicians.

The BOP’s Program Statement P6027.01 provides guidance for
implementing the BOP’s Health Care Provider Credential Verification,
Privileges, and Practice Agreement Program. Under this program, the BOP:
(1) grants clinical privileges to licensed independent practitioners based on
the practitioner’s qualifications, knowledge, skills, and experience;
(2) establishes practice agreements between its licensed independent
practitioners and its non-independent practitioners, such as mid-level
practitioners; (3) establishes protocols that must be followed by other health
care providers, such as clinical nurses and emergency medical technicians;
and (4) performs peer reviews of all providers who function under clinical
privileges or practice agreements.
Privileges, Practice Agreements, and Protocols
The BOP grants clinical privileges to its in-house and contracted
practitioners. Clinical privileges are the specific duties that a health care
provider is allowed to provide to BOP inmates. The following authority is
assigned to grant institution specific clinical privileges.
•

The BOP Medical Director grants privileges for institution physicians
designated as the Clinical Director, including a physician who is
appointed as Acting Clinical Director while the permanent position is
vacant. The BOP Medical Director also grants privileges for Clinical
47

Specialty Consultants and Chief Dental Officers. The Medical
Director delegated privilege-granting authority for the Chief of
Psychiatry at BOP institutions to the BOP’s Chief Psychiatrist.
•

The institution’s Clinical Director grants privileges for other licensed
independent practitioners who deliver medical health care at the
institution, including contractors, consultants, and those involved in
tele-health.

•

The BOP Chief Dental Officer grants privileges for all institution
Chief Dental Officers.

•

The institution Chief Dental Officer grants privileges for institution
dentists.

BOP policy states that clinical privileges can be granted for a period of
not more than 2 years, and that newly employed physicians can be granted
privileges for a period of not more than 1 year. Independent practitioners
are prohibited from practicing medicine within the BOP until they have been
granted privileges to do so by an authorized BOP official.
The individual institutions establish practice agreements between
licensed independent practitioners and non-independent practitioners.
Practice agreements delegate specific clinical or dental duties to nonindependent practitioners under a licensed independent practitioner’s
supervision and are valid for no more than 2 years. Non-independent
practitioners include graduate physician assistants, nurse practitioners, and
unlicensed medical graduates who must be directly supervised by a licensed
independent practitioner. BOP policy prohibits non-independent
practitioners from providing health care within the BOP until a practice
agreement has been established.
The BOP’s other health care providers, such as clinical nurses and
emergency medical technicians, must work under protocols approved by
licensed independent practitioners. A protocol is a plan for carrying out
medical-related functions such as a patient’s treatment regimen.
To determine whether the BOP maintained current privileges, practice
agreements, and protocols for each of its practitioners, we sent survey
questionnaires to 88 BOP institutions. We asked BOP staff at each location
to provide the date and a copy of the latest: (1) privilege-granting
document for licensed independent practitioners, (2) practice agreement for
non-independent practitioners, and (3) protocol for other health care
providers. We analyzed the BOP responses to identify instances when the
48

appropriate authorization document was either not provided to new medical
providers or not renewed for existing medical providers. We identified 134
practitioners who did not have current privileges, practice agreements, or
protocols as shown in the following table.
BOP Medical Practitioners without Current
Privileges, Practice Agreements, or Protocols

Type of
Authorizing
Document
Privileges
Practice Agreement
Protocol
Totals

Practitioners
Requiring
Authorizing
Document
680
466
390
1,536

Practitioners
without
Authorizing
Document
72
42
20
134

Percent
without
Authorizing
Document
11%
9%
5%
9%

Source: Responses by BOP institution officials to OIG survey questionnaire

We also found that 28 of the 42 practitioners without a current
practice agreement had medical service privileges authorized. These
practitioners were non-independent practitioners who should not require
privileges based on the BOP’s policy. While there may be rare instances
where it is appropriate to grant non-independent practitioners privileges
instead of practice agreements, the large number of practitioners incorrectly
authorized indicates that BOP institution officials did not have a good
understanding of BOP policies regarding medical practitioner authorization.
We also noted a similar situation for 9 of the 20 practitioners without current
protocols. These nine practitioners had been granted privileges or were
given practice agreements instead of protocols as required by BOP policy. In
addition, the BOP’s response to our survey questionnaires showed that 267
practitioners were provided multiple levels of authority. For example, 146
practitioners were provided both practice agreements and privileges. Again,
we believe this indicates that BOP staffs at the institutions do not
consistently understand BOP authorization policies.
Based on the responses we received from BOP institution officials
regarding why the practitioners did not have current privileges, practice
agreements, or protocols, we believe that confusion exists among the
officials as to which type of authorization different health care providers
should receive.
Allowing practitioners to provide medical care to inmates without
current privileges, practice agreements, or protocols increases the risk that
the practitioners may provide medical services without having the
qualifications, knowledge, skills, and experience necessary to correctly
perform the services. As a result, the BOP could be subjected to liability
49

claims by inmates if improper medical services are provided by these
practitioners.
The BOP should ensure that practitioners are properly authorized to
provide medical care to inmates. To accomplish this, it is essential that the
BOP establish privileges, practice agreements, or protocols for all
practitioners, as applicable. The BOP must also reevaluate and renew the
privileges, practice agreements, and protocols in a timely manner.
Moreover, the BOP must emphasize the importance of valid privileges,
practice agreements, or protocols and not allow practitioners without current
authorizations to practice medicine in BOP institutions.
Peer Reviews
BOP policy requires that BOP health care providers have a periodic
peer review. A peer is defined as another provider in the same discipline
(physician, dentist, mid-level practitioner, or others) who has firsthand
knowledge of the provider’s clinical performance. Using a sample of the
provider’s primary patient load, the peer reviewer should evaluate the
professional care the provider has given and comment on the provider’s:
•

actual clinical performance;

•

appropriate utilization of resources;

•

participation in, and results of, performance improvement activity;

•

clinical judgment; and

•

technical skills.

BOP health care providers who are privileged or working under a
practice agreement must have at least one peer review every 2 years. Each
Clinical Director, Chief Dental Officer, and Clinical Psychiatrist must also
have a peer review at least once every 2 years.
In our survey questionnaire sent to 88 BOP institutions, we asked the
BOP to provide the date of the last peer review for all providers who were
privileged or working under practice agreements. For the 891 such
providers, the responses to the questionnaire indicated that 430
(48 percent) had not received a peer review within the past 2 years.
We asked BOP officials about the lack of peer reviews. The officials
responsible for more than half of the non-current peer reviews did not
50

provide an explanation. The officials responsible for the remaining noncurrent peer reviews cited the following reasons.
•

The officials rely on the contractors to do peer reviews.

•

The officials believed that the peer review requirement did not
apply to mid-level practitioners, dental assistants, or dental
hygienists.

•

The officials relied on other types of performance reviews instead of
doing the required peer reviews.

Without current peer reviews, the BOP has a higher risk of not
detecting circumstances where providers may not be giving adequate
medical care to inmates. If inadequate professional care goes undetected,
the providers may not receive the training or supervision needed to improve
the delivery of medical care. Moreover, inadequate care by a practitioner
without a current peer review also increases the risk of BOP liability arising
from any formal complaints or medical malpractice suits filed by inmates.
The BOP’s Health Care Performance Measures
The BOP has also established national performance measures for
health care, including annual targets or goals, for management of:
(1) hypertension, (2) cholesterol, (3) diabetes, (4) HIV, (5) tuberculosis,
(6) asthma, (7) breast cancer, (8) cervical cancer, and (9) pregnancy.
Appendix VIII shows how each performance measure is calculated and the
target percentage, or goal, that BOP established each performance measure.
A BOP official told us that the BOP had not established written
procedures to be followed by institutions in accumulating and submitting
performance measure data to headquarters. According to the official, the
institutions have been asked since 2004 to submit quarterly reports
containing data for the performance measures to BOP’s Health Services
Division. However, the official noted that compliance to this request was
voluntary.
In our survey questionnaire, we asked institution officials if they had
completed the performance measure calculations for the nine performance
measures for calendar year 2004 through the first quarter of calendar year
2007. The following table details the 99 responses from officials at the 88
BOP locations.

Performance Measure
Calculations Completed
for Calendar Year
2004
2005
2006
2007 (1st Quarter)

Yes
59
77
87
90

BOP Response26
Not
No
Applicable
Response
No
28
10
2
14
4
4
11
0
1
7
1
1

Source: BOP responses to OIG survey questionnaires

Based on the responses, institutions completing the performance
measure calculation increased each year since 2004. We followed up with
BOP officials for institutions that did not complete performance measure
calculations and the officials usually could not provide an explanation for
why the measures were not completed and said that the person who was
responsible for completing the calculations was no longer at the institution.
Officials who did provide an explanation usually attributed not completing
the performance measures to staffing shortages.
In our survey, we also asked the BOP to provide a copy of the
performance measure reports completed. We analyzed performance
measure reports and found that BOP institutions often did not meet the
target levels established for the nine target goals. For the 9 health care
performance measures we tested, we found that the institutions reported
performance below the target level for more than 20 percent of the quarters
reported for 7 of the 9 performance measures as shown in the following
table.

Performance
Measure
Clinical Management
of Hypertension
Clinical Management
of Lipid Level
Clinical Management
of Diabetes – HbA1C
Level
Clinical Management
of HIV/ Ribonucleic
Acid Level

Number of
Reporting
Institutions

Number of
Quarters
Reported

Number of
Quarters
Below
Target

Percentage
of Quarters
Below
Target

728

153

21%

723

437

60%

729

285

39%

723

184

25%

The 99 total responses to our survey questions was more than the 88 BOP
locations surveyed because 6 of the locations surveyed submitted separate responses for
the 17 BOP institutions at the locations. Performance measures were not applicable for
some institutions primarily because the institutions are new and were not active for the
years tested.

Performance
Measure
Completion of
Isoniazid Treatment
Asthma Related
Hospitalization or
Mortality
Breast Cancer
Screening
Cervical Cancer
Screening
Pregnancy Test at
Intake

Number of
Reporting
Institutions

Number of
Quarters
Reported

Number of
Quarters
Below
Target

Percentage
of Quarters
Below
Target

602

169

28%

601

131

21%

131

21%

131

10%

Source: OIG analysis of BOP performance data

We asked a BOP official at the Health Services Division if the division
staff review the performance reports submitted and take action to help the
institutions improve their performance and reach target levels. The official
informed us that the Office of Quality Management staff receive the
performance reports, perform a trend analysis of the results, and summarize
the results in the Office of Quality Management’s Annual Report. However,
the official also told us that institution participation in reporting the
performance measures is voluntary and they do not develop agency-wide
corrective actions when the performance is below target levels. We
concluded that unless BOP officials more closely monitor the performance
data submitted and take actions to help the institutions improve
performance in areas not meeting target levels, the institutions will likely
continue to not provide the expected level of health care to inmates.
The BOP official also stated that instructions have not been provided to
the institutions on how to properly accumulate and report data related to the
performance measures. Consequently, a BOP Health Services Division
official said that the institutions are inconsistent in how they accumulate and
report performance data. We were informed by this official that the BOP is
developing a training program to educate institution staff on how to properly
accumulate and report performance data. According to the Chief of the
BOP’s Quality Management Section, a meeting was held in December 2007
with the institution Health Services Administrators to discuss collecting of
national performance measure data. Another meeting is planned for January
2008 to discuss with Regional Medical Directors any adjustments needed to
the performance measurement system.

Conclusion
The BOP monitors its health care providers through various methods
such as performing program reviews of institution operations, reviewing
medical provider skills and qualifications and providing authorization
documents based on the review results, and requiring institutions to
accumulate and submit to BOP headquarters data on health-related
performance measures. We found that the BOP has corrected deficiencies at
the institutions where deficiencies were found, but it does not generally
develop and issue guidance to correct systemic deficiencies found during the
reviews. We believe that unless BOP-wide guidance is issued for systemic
deficiencies identified through program reviews, deficiencies existing at other
BOP institutions likely will remain uncorrected.
We also found that the BOP allowed health care providers to practice
medicine without valid authorizations. Allowing practitioners to provide
medical care to inmates without current privileges, practice agreements, or
protocols increases the risk that the practitioners may provide medical
services without having the qualifications, knowledge, skills, and experience
necessary to correctly perform the services. In addition, the BOP could be
subjected to liability claims by inmates if improper medical services are
provided by these practitioners.
In addition, providers have not had their medical practices evaluated
by a peer as required by BOP policy. Without a current peer review the BOP
has a higher risk of providers giving inadequate professional care to inmates.
Also, if inadequate professional care goes undetected, the providers may not
receive the training or supervision needed to improve the delivery of medical
care.
Institutions report performance measure data to BOP’s Office of
Quality Management, which performs trend analyses of the results and
summarizes the results in its annual report. However, a senior official told
us that the BOP does not develop agency-wide corrective actions when the
performance is below target levels. We believe it is essential that the BOP
take corrective actions when performance is below targets to help ensure
that inmates are provided adequate medical care.

Recommendations
We recommend that the BOP:
5.

Develop a process to use the program summary reports prepared by the
Program Review Division to develop or clarify agency-wide guidance on
systemic deficiencies found during program reviews.

Ensure initial privileges, practice agreements, or protocols are
established for all practitioners, as applicable.

Ensure privileges, practice agreements, and protocols are revaluated
and renewed in a timely manner.

Ensure that practitioners are not allowed to practice medicine in BOP
institutions without current privileges, practice agreements, or
protocols.

Ensure that peer reviews of all providers are performed within the
prescribed timeframes.

10. Until the training program on accumulating and reporting performance
data is implemented, issue guidance to all institutions on how to
accumulate and report data for the health care performance measures
to ensure consistency in the way institutions collect and report
performance data. Once the training program is fully developed, ensure
that appropriate institution staff receive the training.
11. Establish a process for reviewing the health care performance measures
reported by institutions that includes actions that will be taken when
institutions are not meeting the target performance levels.

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STATEMENT ON COMPLIANCE WITH
LAWS AND REGULATIONS
The Federal Managers Financial Integrity Act of 1982 requires agencies
to establish and maintain internal controls to provide assurance that agency
funds are safeguarded against waste, loss, unauthorized use, or
misappropriation. The Office of Management and Budget Circular No. A-123,
Management’s Accountability and Control defines management’s
responsibilities related to internal control. The BOP’s controls for providing
necessary medical care to inmates are established primarily by BOP program
statements and clinical practice guidelines. To obtain reasonable assurance
that the BOP complied with laws and regulations that, if not complied with,
could have a material effect on the BOP’s provision of health care to
inmates, we tested the BOP’s compliance with BOP’s guidelines for providing
inmate health care contained in the following BOP program statements and
clinical practice guidelines.
•

P1210.023 Management Control and Program Review

•

P6010.02, Health Services Administration

•

P6013.01, Health Services Quality Improvement

•

P6027.01, Health Care Provider Credential Verification, Privileges,
and Practice Agreement Program

•

P6031, Patient Care

•

P6190.03, Infectious Disease Management

•

P6270.01, Medical Designations and Referral Services for Federal
Prisoners

•

Preventive Health Care Clinical Practice Guideline

Except for instances of noncompliance identified in the Findings and
Recommendations section of this report, we did not identify any other
instances of noncompliance with the policies we tested.

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STATEMENT ON INTERNAL CONTROLS
In planning and performing our audit of the BOP's Efforts to Manage
Inmate Health Care, we considered the BOP's internal controls for the
purpose of determining our auditing procedures. The evaluation was not
made for the purpose of providing assurance on the internal control
structure as a whole; however, as shown below, we noted certain matters
that we consider reportable conditions under generally accepted government
auditing standards.27
Finding I
•

The BOP did not maintain documentation of any preliminary costbenefit analyses or post-implementation analyses to identify costs
reduced or contained for its health care initiatives.

•

The BOP’s institutions did not always provide recommended
preventative medical services to inmates.

Finding II
•

The BOP institutions had not established controls to ensure that
contract administration deficiencies found during OIG audits of
medical contracts at other BOP institutions were corrected.

•

The BOP had not addressed agency-wide the systemic deficiencies
found during OIG audits of BOP medical contracts.

Finding III
•

The BOP had not addressed agency-wide the systemic deficiencies
found during the Program Review Division’s program reviews at
BOP institutions.

•

The BOP had not established effective controls to ensure that BOP
health care providers were provided privileges, practice
agreements, or protocols as required by BOP policy.

Reportable conditions involve matters coming to our attention relating to
significant deficiencies in the design or operation of the internal control structure that, in our
judgment, could adversely affect the ability of the BOP to administer health care to inmates.

•

The BOP had not established effective controls to ensure that BOP
health care providers received an internal peer review as required
by BOP policy.

•

The BOP had not established an effective system for monitoring
institution progress against performance measures and taking
actions when performance was below target levels.

Because we are not expressing an opinion on the BOP's overall internal
control structure, this statement is intended solely for the information and
use of the BOP in managing inmate health care.

ACRONYMS AND ABBREVIATIONS
Act
AIDS
BEMR
BEMRx
BOP
CD
CMS
COSTEP
CPI
CY
DOL
FCC
FCI
FDC
FMC
FPC
FSC
FSL
FTC
FY
GAO
HbA1C
HealthONE
HHS
HIV
HSD
HSU
MCC
MDC
MDI
MED
MRC
MRI
MRL

Federal Managers Financial Integrity Act of 1982
Acquired Immunodeficiency Syndrome
Bureau Electronic Medical Records
Bureau Electronic Medical Records Pharmacy Module
Federal Bureau of Prisons
Clinical Director
Correctional Medical Services
Commissioned Officer Student Training Extern Program
Consumer Price Index
Calendar Year
Department of Labor
Federal Correctional Complex
Federal Correctional Institute
Federal Detention Center
Federal Medical Center
Federal Prison Camp
Financial Services Center
Federal Satellite Low
Federal Transfer Center
Fiscal Year
Government Accountability Office
Hemoglobin A1C test
Hospital Corporation of America-HealthONE, L.L.C.
Department of Health and Human Services
Human Immunodeficiency Virus
BOP’s Health Services Division
Health Services Unit
Metropolitan Correctional Center
Metropolitan Detention Center
Medical Development International
Medium Security
Medical Referral Centers
Magnetic Resonance Imaging
Medical Referral Laboratory

MRSA

Methicillin-Resistant Staphylococcus Aureus

OIG

Office of the Inspector General

PAP

Papanicolaou Test

PCPT

Primary Care Provider Team

PHS

Public Health Service

PMC

Parkview Medical Center

TB
UMass

Tuberculosis
Joint venture between the University of Massachusetts
Medical School and UMass Memorial Health Care,
Incorporated

USMCFP

United States Medical Center for Federal Prisoners

USP

United States Penitentiary

Department of Veterans Affairs

WMH

Wayne Memorial Hospital

APPENDIX I
Audit Objectives, Scope, and Methodology
Objectives
The objectives of this audit were 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.
Scope and Methodology
We performed the audit in accordance with Government Auditing
Standards and included tests and procedures necessary to accomplish the
objectives. We performed the audit from January 16, 2007, to
November 14, 2007. We conducted fieldwork at the following locations:
BOP Headquarters
USP Atlanta
FMC Carswell
USP Lee
FCC Terre Haute
FCC Victorville

Washington, D.C.
Atlanta, Georgia
Forth Worth, Texas
Jonesville, Virginia
Terre Haute, Indiana
Victorville, California

Health Care Costs
To determine whether the BOP appropriately contained health care
costs we:
•

obtained and analyzed health care cost data from FYs 2000 to
2007 to identify long-term trends in costs;

•

identified the major BOP cost containment initiatives since
FY 2000;

•

reviewed each BOP initiative to identify the original implementation
plan, budget, and anticipated impact on costs and then assessed
the implementation of each initiative; and

•

evaluated the cumulative effect of the initiatives on health care
costs.

Medical Care Services Provided
We initially determined that the BOP’s Preventive Health Care Clinical
Practice Guideline included the appropriate provisions to use in testing the
BOP’s overall inmate health care. We selected this guideline as the basis for
our testing because it:
•

addressed care for all inmates, instead of just inmates with specific
illnesses;

•

included the diagnostic procedures for all but 2 of the chronic
conditions addressed in the other 15 guidelines;

•

contained definitive and finite medical services that could be tested
for completion, while testing of services in the other 15 guidelines
would require medical expertise; and

•

is a primary objective of the BOP in its efforts to contain costs and
promote health and prevent disease.

From the medical procedures listed in the guideline, we developed a
list of 30 medical procedures to test. We selected a preliminary statistical
sample of 251 inmates at USP Atlanta, because our sample was
representative of the inmates incarcerated there. We reviewed the medical
records of the inmates in our sample and determined if they received the
applicable service required based on age or medical need. To validate our
testing, we asked a USP Atlanta Health Service Unit official to verify the
results of our review to ensure that we had not overlooked any reference to
the provision of any medical service tested. Our preliminary test results
showed that inmates did not receive all the necessary health care services,
and we expanded our testing to include other BOP institutions.
For our expanded audit testing, we selected 859 additional inmates at
4 additional BOP locations within 4 of the BOP’s regions. Including the
preliminary sample reviewed at USP Atlanta, our sample consisted of 1,110
inmates at 5 BOP locations in 5 BOP regions. Appendix IV explains our
sampling methodology. The sample size we tested at each location is shown
in the following table.

Sample
Location of Institutions
Size
USP Atlanta
251
USP Lee
133
FCC Terre Haute
249
FMC Carswell
127
FCC Victorville
350
Total
1,110
Source: OIG sample from BOP inmate population data

Medical Services Contractor Oversight
To determine whether the BOP effectively administered its medical
services contracts we:
•

reviewed previous OIG audits of comprehensive BOP medical
services contracts and identified similar conditions and causes of
contract administration deficiencies existing at multiple BOP
institutions;

•

interviewed personnel at five BOP institutions and determined if the
causes for the deficiencies also existed at those BOP facilities;

•

used a questionnaire to survey all other BOP institutions to
determine if the causes for the deficiencies also existed at those
institutions; and

•

determined whether the BOP developed and issued policies and
procedures to address any systemic deficiencies.

To determine whether the BOP effectively monitored its medical
services providers we:
•

evaluated the BOP’s review process for monitoring contractor
performance at the national, regional, and institutional levels;

•

determined whether the five BOP institutions selected for testing
had implemented adequate monitoring processes of their health
care providers;

•

surveyed BOP institutions through a questionnaire to determine if
they had implemented adequate monitoring processes for health
care providers;

•

assessed whether the BOP’s monitoring system for health care is
capable of detecting the types of deficiencies identified in this and
prior OIG audits; and

•

determined whether the BOP performed trend analyses of its
program review findings to identify systemic deficiencies and issued
BOP-wide guidance to address the weaknesses.

APPENDIX II
BOP Initiatives since FY 2000 to Improve the Effectiveness
and Efficiency of Inmate Health Care
Initiative
1. Medical Designations
Program

2. Medical Staff Restructuring

3. Tele-medicine
4. Electronic Medical Records

5. Medical Claims
Adjudication

Description
This initiative involves: (1) assigning each inmate a care
level from 1 to 4, with 1 being the healthiest inmates and
4 being inmates with the most significant medical
conditions; (2) assigning each BOP institution a care level
designation from 1 to 4 based on the care level of inmates
the institution is staffed and equipped to handle;
(3) staffing each institution based on its designated care
level; and (4) moving inmates between institutions to
match each inmate’s care level to the care level of the
institution.
Under this initiative, the BOP established staffing
guidelines for Care Level 1, 2, and 3 institutions. Because
the existing staffing of the institutions did not always
match the care level staffing guidelines, the BOP had to
move medical staff throughout the BOP to implement the
guidelines. Institutions that had staff in positions contrary
to the guidelines were required to either move the staff to
another facility or reassign the staff to another authorized
position in the facility.
This initiative involves the remote delivery of health care
using telecommunications technologies, such as
video-conferencing.
This initiative involves automating the medical records for
inmates. The initial system included the capability to:
(1) track comprehensive history and physical examination
information, (2) schedule inmate medical visits when
required, and (3) track medical-related supplies and
equipment issued to inmates. The BOP subsequently
added a pharmacy module to the system to manage the
medications provided to inmates.
This initiative is designed to ensure the BOP properly pays
medical claims and complies with requirements of the
Prompt Payment Act. In April 2004, the BOP began
researching the feasibility of using third-party medical
claims processing services. The BOP developed a
Statement of Work defining its requirements for medical
claims adjudication services and in July 2006, the BOP
issued a Request for Information asking interested
commercial vendors to submit specific information about
the claims processing services they provide. From July
2006 to September 2007, the BOP refined its requirements
and finalized the Statement of Work in September 2007.
The BOP expects to award a contract for the medical
claims adjudication services early in calendar year 2008.

Initiative
6. Medical Reference Laboratory

7. Medical Equipment

8. Inmate Co-payment

Description
In 2001, the BOP established a Medical Reference
Laboratory (MRL) system at the: (1) United States Medical
Center for Federal Prisoners, Springfield, Illinois;
(2) Federal Medical Center, Rochester, Minnesota; and
(3) Federal Medical Center, Butner, North Carolina. This
initiative was designed to contain or reduce health care
costs by enabling non-medical facilities within the BOP to
collect and ship specimens to one of the three MRLs, where
the laboratory tests could be performed at a lower cost
than through individual contracts throughout the country.
The BOP implemented this initiative in 1997 requiring that
a senior official at BOP headquarters approve all purchases
of medical equipment with a single item value of more
than $1,000. BOP subsequently raised the threshold to
$5,000. To obtain approval, the requesting institution
must submit a Major Equipment Justification and include
evidence that the institution researched alternatives to find
the best value for the equipment being acquired. This
helps ensure that BOP institutions are not frivolous with
equipment requests and spending. Under the initiative the
BOP also consolidates like purchases submitted for
approval, which permits better pricing on bulk purchases
through one of the Department of Defense’s Defense
Supply Centers. The Defense Supply Centers primarily
purchase items such as food, clothing and textiles,
pharmaceuticals, medical supplies, construction items, and
other equipment to support the U.S. military. The centers
also use their purchasing power to obtain such items for
other federal agencies at a lower cost.
This initiative was implemented in October 2005 and
required inmates to pay a $2 fee when requesting certain
types of medical evaluations. The BOP does not charge
indigent inmates a co-payment fee. The BOP also does not
charge inmates for certain medical services such as visits
related to a chronic medical condition, preventive health
visits, or evaluations related to pregnancy. The initiative
was designed to reduce the number of unnecessary inmate
initiated medical visits. A BOP analysis of data for the first
year of implementation showed a significant decrease in
the number of inmate initiated medical visits.

Initiative
9. Medical Coverage

10. Staffing Provider Teams

11. Federal Resource Sharing

Description
In January 2005, the BOP discontinued the requirement for
24-hour on-site medical coverage at non-medical
institutions. Instead of 24-hour on-site medical coverage,
each institution is now required to have a plan in place for
providing emergency and urgent care services to inmates
consistent with American Correctional Association
standards. The plan should include a team of first
responders trained to use the automatic external
defibrillator and perform cardiopulmonary resuscitation as
clinically indicated. This change allowed institutions to
reassign staff to the day shift when inmates require the
most medical care. According to the BOP, the reduction in
premium pay for the 8-hour overnight period that is no
longer staffed resulted in significantly reduced staffing
costs.
The BOP has traditionally provided health care to inmates
based on a “military” model utilizing the concept of sick
call and same-day treatment. Any available provider
evaluated an inmate, and this led to “practitioner
shopping” by the inmates, and inconsistency in the
approach to treatment of episodic complaints. In 2005,
the BOP began implementing the Patient Care Provider
Team concept, where inmates are assigned to a primary
provider team that manages both the chronic and episodic
care of the inmate. This approach is designed to improve
the consistency of treatment and eliminate the ability of
the inmate to consume valuable staff resources by going
from provider to provider for treatment for the same
complaint. According to the BOP, implementation of
provider teams has reduced duplicate diagnostic tests,
consultations, and treatments.
This is an ongoing initiative through which the BOP has
existing contracts with the Department of Veterans Affairs
to obtain local medical services at the facility level, such as
laboratory services, tele-medicine, HIV tests, and others.
The initiative is designed to contain or reduce costs for
these medical services by taking advantage of the
“economies of scale” available through the Department of
Veterans Affairs that are not available to the BOP or
private sector laboratories.

Initiative
12. Health Promotion

13. Consolidation Pilot Project
with the United States
Marshals Service

14. National Cardiopulmonary
Resuscitation and Automated
External Defibrillator
Contract

15. National Medical Air
Transportation Contract

16. National Comprehensive
Medical Contract and
Preferred Provider
Organization

Description
In 2000, the BOP had a three-person team in its Health
Services Division that worked on Health Promotion and
Disease Prevention initiatives. In recent years, the BOP
disbanded this team and the functions of promoting health
within the inmate population were realigned to appropriate
groups within the Health Services or other divisions. In
2005, the Health Services Division issued its Preventive
Health Care Clinical Practice Guidelines outlining risk-based
screening for inmates to identify and monitor those at risk
for developing serious medical conditions such as diabetes,
sequels of HIV infection, and heart disease. This initiative
is designed to promote better health among inmates
beginning at admission to the facility and continuing
throughout the inmate’s incarceration. This guideline was
revised in April 2007.
This project was conducted in FY 2000 at three BOP
institutions and was designed to determine the financial,
personnel, medical, and other resources that would be
necessary for the BOP to assume responsibility for medical
services for the United States Marshals Service’s inmates
housed in BOP facilities. The project was deemed
successful and expanded to include the following BOP
institutions: all existing Federal Medical Centers (FMC) in
June 2000; the Brooklyn Metropolitan Detention Center
(MDC) in May 2005; and the Guaynabo MDC, Fort Devens
FMC, Seagoville FCI, and Atlanta FCI in October 2006. The
Marshals Service reimburses the BOP for expenses incurred
by the BOP for providing community-based medical care to
the U.S. Marshals Service’s prisoners housed at BOP
institutions.
This initiative is designed to provide cardiopulmonary
resuscitation and automated external defibrillator training
and certification to BOP health care staff through a
nationally negotiated contract with standardized pricing.
The BOP approved and submitted a Request for
Contracting Action in May 2007 and the BOP expects to
award the contract early in calendar year 2008.
This initiative is designed to provide a single nationwide
contract for medical air transportation services for all BOP
institutions at standardized and best-value pricing. During
FY 2007, the BOP conducted market research and issued a
Request for Information. The BOP plans to award the
contract during FY 2008.
This initiative is designed to provide a contract for health
care services for all of the BOP’s institutions at
standardized and best-value pricing. At the end of
FY 2007, the BOP was conducting market research for this
initiative.

Initiative
17. Catastrophic Case
Management

Description
This initiative is designed to: (1) implement a catastrophic
case management system to provide clinical oversight and
intervention of complex and specialized care cases, and
(2) provide funding reimbursement to the institutions to
mitigate the fiscal impact those cases have on the
institutions’ medical budgets. As of the end of FY 2007,
the BOP had drafted preliminary procedures and protocols
for internal review and comment. The BOP anticipates
submitting this initiative to the BOP’s Executive Staff for
consideration in FY 2008.
18. Mobile Surgery
This initiative is designed to provide a national contract for
mobile surgery services at standardized and best-value
pricing. The contract is expected to provide on-site
surgical services through a mobile surgical unit in lieu of
sending inmates outside of the institutions for surgery.
The BOP formed a workgroup during FY 2007 and identified
three institutions in the Southeast Region to pilot this
initiative. Further implementation will be predicated on the
success of the pilot, status of existing medical services
contracts, and the ability of the contractor to expand the
services to other BOP institutions.
19. Magnetic Resonance
This initiative is designed to provide a national contract for
Imaging, Computerized Axial magnetic resonance imaging, computerized axial
Tomography, and
tomography, and mammogram services at standardized
Mammography
and best-value pricing. The BOP began market research
during FY 2007.
20. Staffing and Recruiting
Through this initiative begun in FY 2007, the BOP is
attempting to identify novel, unique, and unconventional
strategies to recruit and retain health care workers, with
the understanding that there is and will continue to be
shortages of trained and qualified health care workers in
the United States and worldwide.
Source: Data provided by BOP officials

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APPENDIX III
Medical Services Selected for Testing from the BOP’s
Preventive Health Care Clinical Practice Guideline
Medical Service
1. The Inmate History, Part 1 of Form
360, was completed by the inmate
during intake screening.
2. The Medical Assessment, Part 2 of
Form 360 was completed by the
medical practitioner during intake
screening.
3. New inmates were tested for
tuberculosis (TB), or transferred
inmates were confirmed for TB testing
within 48 hours of entering the
institution.
4. Inmates were given a rapid plasma
reagin test during intake
screening to test for syphilis.
5. Inmates were given a test for
chlamydia during intake screening.
6. Inmates were given a Measles,
Mumps, and Rubella vaccine during
intake screening.
7. Inmates were given a complete
physical examination within 14 days
of arriving at the institution to
include: (1) medical and mental
assessments, (2) dental assessment,
and (3) appropriate laboratory and
diagnostic tests. Also, the completion
of the physical examination was
signed off on the Standard Form 88
by the institution Clinical Director.
8. Inmates had received or refused a
current pneumococcal immunization.
9. Inmates had received or refused an
annual influenza immunization.
10. Inmates had received or refused a
current Measles, Mumps, and Rubella
vaccination.
11. Inmates had received or refused a
current tetanus vaccination.
12. Inmates had received or refused a
current Hepatitis A vaccine.
13. Inmates had received or refused a
current Hepatitis B test.
14. Inmates had received or refused a
current Hepatitis C test.

Applicability
All inmates.
All inmates.

All inmates.

All female inmates and male inmates
with identified risk factors.
All females inmates under age 25 with
identified risk factors.
All female inmates of child-bearing-age if
not received as an adult.
All inmates.

All inmates age 65 or over and inmates
under age 65 with identified risk factors.
All inmates over age 50.
All inmates born after 1956.
All inmates every 10 years.
All inmates with identified risk factors.
All inmates with identified risk factors.
All inmates with identified risk factors.

Medical Service
15. Inmates had received or refused an
HIV-1 test.
16. Inmates had received or refused an
HIV-2 test.
17. Inmates tested for TB annually (past
positive determination or X-ray if
confirmed past positive).
18. Inmates with chronic care conditions
were evaluated every 6 months.
19. Inmates had their cholesterol and
high-density lipoproteins checked
once every 5 years.
20. Inmates had received a calculation of
their risk for cardiovascular disease
every 5 years.
21. Inmates had received a fasting
plasma glucose test for diabetes
every 3 years.
22. Inmates had been checked for
hypertension by having their blood
pressure checked either annually or
every 3 years, as applicable.
23. Inmates had been checked for
obesity by receiving a calculation of
their body mass index either
annually or every 3 years, as
applicable.
24. Inmates had received a fecal occult
blood test to check for colorectal
cancer as recommended.
25. Inmates had received a vision
screening as recommended.
26. Inmates had received a hearing
screening as recommended.
27. Inmates had received an abdominal
ultrasound test to check for an
abdominal aneurysm.
28. Inmates had received a papanicolaou
test (Pap smear) to test for cervical
cancer either annually or every 3
years, as applicable.

Applicability
All inmates with identified risk factors.
All inmates with identified risk factors.
All inmates.
All inmates with chronic care conditions.
All male inmates age 35 and over, all
female inmates age 45 and over, and all
other inmates age 20 and over with
identified risk factors.
All diabetic inmates age 40 and over, all
male inmates age 40 and over, and all
female inmates age 45 and over.
All inmates age 45 and over with
identified risk factors.
Annually - All inmates age 50 or over.
Every 3 Years – All inmates under age
50.
Annually - All inmates age 50 or over.
Every 3 Years – All inmates under age
50.
All inmates age 50 and over.
All inmates age 65 and over.
All inmates age 65 and over and all
other inmates in an occupational risk
assignment.
All male inmates with a history of
smoking and age 65 or over.
Annually - All female inmates under age
31.
Every 3 Years – All female inmates age
31 to 65.

Medical Service
29. Inmates received a mammogram to
check for breast cancer either
annually or every 2 years, as
applicable.

Applicability
Annually – Offered to all female inmates
and given to all female inmates age 40
and over with identified risk factors.

Every 2 Years – All female inmates age
40 and over without identified risk
factors.
30. Inmates received bone density
All female inmates age 60 to 64 with
screening to check for osteoporosis
identified risk factors and all female
as recommended.
inmates age 65 and over.
Source: BOP Preventive Health Care Clinical Practice Guideline

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APPENDIX IV
Sample Methodology
The population was defined as the Federal Prison inmates in multiple
federal facilities at five different locations. The defined population contained
14,026 inmates (sampling units) in multiple BOP facilities located in the
following five BOP locations.
•

Atlanta, Georgia

•

Carswell, Texas

•

Lee County, Virginia

•

Terre Haute, Indiana

•

Victorville, California

Considering that the inmate health care administration could vary from
location to location, we employed a stratified random sampling design to
provide effective coverage and to obtain precise estimates of the statistic.
In addition, the characteristics of the population that affect the test
questions are the inmate age, gender, and facility type. Incorporating these
additional variables into the sampling plan, a multi-stage stratified sample
design was employed. The primary strata was BOP facility locations. The
secondary strata was facility type. The last strata was age groups. The
sample allocation considered to different strata was proportional to the
population sizes. The details of sample sizes, sample allocation to different
locations, and the test result statistics are presented in the body of the
report.

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APPENDIX V
BOP Institutions and Inmates Housed
As of November 29, 200728
State

Care
Level

1. ALDERSON FPC

1,141

2. ALLENWOOD LOW FCI

1,388

3. ALLENWOOD MED FCI

1,431

4. ALLENWOOD USP

1,129

5. ASHLAND FCI

1,233

325

2,108

506

1,126

129

1,218

186

9. BEAUMONT LOW FCI

1,861

10. BEAUMONT MED FCI

1,707

11. BEAUMONT USP

1,496

538

1,602

BECKLEY-CAMP

417

13. BENNETTSVILLE FCI

1,650

139

1,483

130

1,616

181

2,565

Institution

ASHLAND-CAMP
6. ATLANTA USP
ATLANTA-CAMP
7. ATWATER USP
ATWATER-CAMP
8. BASTROP FCI
BASTROP-CAMP

BEAUMONT USP-CAMP
12. BECKLEY FCI

BENNETTSVILLE-CAMP
14. BIG SANDY USP
BIG SANDY-CAMP
15. BIG SPRING FCI
BIG SPRING-CAMP
16. BROOKLYN MDC
28

Inmates

As of November 29, 2007, the BOP housed an additional 33,354 inmates in
privately managed, contracted, or other facilities. Some BOP locations incorporate more
than one BOP institution. For instance, the BOP has two facilities at its Ashland, Kentucky,
location: Ashland FCI and Ashland-CAMP.

State

Care
Level

17. BRYAN FPC

971

18. BUTNER FMC

956

19. BUTNER LOW FCI

1,308

20. BUTNER MED I FCI

725

BUTNER-CAMP

314

21. BUTNER MED II FCI

1,245

22. CANAAN USP

1,513

125

1,540

257

24. CHICAGO MCC

730

25. COLEMAN I USP

1,627

26. COLEMAN II USP

1,635

27. COLEMAN LOW FCI

2,017

28. COLEMAN MED FCI

1,727

489

1,160

297

1,248

193

993

121

1,140

333

33. DULUTH FPC

812

34. EDGEFIELD FCI

1,647

542

1,115

262

1,860

581

Institution

CANAAN-CAMP
23. CARSWELL FMC
CARSWELL-CAMP

COLEMAN MED FCI-CAMP
29. CUMBERLAND FCI
CUMBERLAND-CAMP
30. DANBURY FCI
DANBURY-CAMP
31. DEVENS FMC
DEVENS-CAMP
32. DUBLIN FCI
DUBLIN-CAMP

EDGEFIELD-CAMP
35. EL RENO FCI
EL RENO-CAMP
36. ELKTON FCI
ELKTON-FSL

Inmates

State

Care
Level

905

158

1,118

304

1,437

113

484

534

41. FLORENCE FCI

1,208

42. FLORENCE HIGH USP

987

43. FORREST CITY FCI

2,021

310

44. FORREST CITY MED FCI

1,666

45. FORT DIX FCI

2,051

413

46. FORT WORTH FCI

1,754

47. GILMER FCI

1,708

131

1,192

315

49. GUAYNABO MDC

1,357

50. HAZELTON USP

1,651

HAZELTON-CAMP

130

HAZELTON-FEMALE CAMP

622

923

122

52. HONOLULU FDC

641

53. HOUSTON FDC

1,010

54. JESUP FCI

1,101

JESUP-CAMP

152

JESUP-FSL

639

Institution
37. ENGLEWOOD FCI
ENGLEWOOD-CAMP
38. ESTILL FCI
ESTILL-CAMP
39. FAIRTON FCI
FAIRTON-CAMP
40. FLORENCE ADMAX USP
FLORENCE USP-CAMP

FORREST CITY FCI-CAMP

FORT DIX-CAMP

GILMER-CAMP
48. GREENVILLE FCI
GREENVILLE-CAMP

51. HERLONG FCI
HERLONG-CAMP

Inmates

State

Care
Level

1,060

LA TUNA-CAMP

242

LA TUNA-FSL (EL PASO)

411

1,602

404

1,523

131

1,531

571

1,476

297

60. LOMPOC FCI

1,538

61. LOMPOC USP

1,785

504

1,305

LORETTO-CAMP

150

63. LOS ANGELES MDC

953

64. MANCHESTER FCI

1,115

513

1,215

297

891

304

511

136

1,247

320

1,202

337

1,100

385

1,696

Institution
55. LA TUNA FCI

56. LEAVENWORTH USP
LEAVENWORTH-CAMP
57. LEE USP
LEE USP-CAMP
58. LEWISBURG USP
LEWISBURG-CAMP
59. LEXINGTON FMC
LEXINGTON-CAMP

LOMPOC USP-CAMP
62. LORETTO FCI

MANCHESTER-CAMP
65. MARIANNA FCI
MARIANNA-CAMP
66. MARION USP
MARION-CAMP
67. MCCREARY USP
MCCREARY-CAMP
68. MCKEAN FCI
MCKEAN-CAMP
69. MEMPHIS FCI
MEMPHIS-CAMP
70. MIAMI FCI
MIAMI FCI-CAMP
71. MIAMI FDC
82

Inmates

State

Care
Level

72. MILAN FCI

1,479

73. MONTGOMERY FPC

911

74. MORGANTOWN FCI

1,118

75. NEW YORK MCC

752

76. OAKDALE FCI

1,338

77. OAKDALE FDC

497

OAKDALE FDC-CAMP

152

78. OKLAHOMA CITY FTC

1,541

79. OTISVILLE FCI

1,094

118

1,084

206

1,153

PEKIN-CAMP

303

82. PENSACOLA FPC

685

83. PETERSBURG FCI

1,312

346

84. PETERSBURG MED FCI

1,828

85. PHILADELPHIA FDC

1,181

86. PHOENIX FCI

1,080

325

1,494

POLLOCK-CAMP

133

88. RAY BROOK FCI

1,220

89. ROCHESTER FMC

873

90. SAFFORD FCI

804

91. SAN DIEGO MCC

994

92. SANDSTONE FCI

1,224

93. SCHUYLKILL FCI

1,317

308

1,908

170

Institution

OTISVILLE-CAMP
80. OXFORD FCI
OXFORD-CAMP
81. PEKIN FCI

PETERSBURG FCI-CAMP

PHOENIX-CAMP
87. POLLOCK USP

SCHUYLKILL-CAMP
94. SEAGOVILLE FCI
SEAGOVILLE-CAMP
83

Inmates

State

Care
Level

95. SEATAC FDC

976

96. SHERIDAN FCI

1,355

SHERIDAN-CAMP

499

97. SPRINGFIELD USMCFP

1,117

98. TALLADEGA FCI

995

TALLADEGA-CAMP

367

99. TALLAHASSEE FCI

1,249

100. TERMINAL ISLAND FCI

1,063

101. TERRE HAUTE FCI

1,226

399

102. TERRE HAUTE USP

1,530

103. TEXARKANA FCI

1,444

TEXARKANA-CAMP

354

104. THREE RIVERS FCI

1,157

362

105. TUCSON FCI

778

106. TUCSON USP

775

123

107. VICTORVILLE MED I FCI

1,513

108. VICTORVILLE MED II FCI

965

242

109. VICTORVILLE USP

1,485

110. WASECA FCI

1,080

111. WILLIAMSBURG FCI

1,622

140

112. YANKTON FPC

859

113. YAZOO CITY FCI

1,863

137

1,474

Institution

TERRE HAUTE FCI-CAMP

THREE RIVERS-CAMP

TUCSON-CAMP

VICTORVILLE MED II-CAMP

WILLIAMSBURG-CAMP

YAZOO-CAMP
114. YAZOO CITY MED FCI
Total Inmates

Inmates

166,794

Source: BOP website

APPENDIX VI
Summary of BOP Program Statements Related
to the Provision of Medical, Dental, and
Mental Health Services
The BOP has developed and issued the following program statements
that provide BOP policy and guidance related to the provision of medical,
dental, and mental health services to BOP inmates.
P6010.02 Health Services Administration — requires the BOP to deliver
necessary health care to inmates effectively in accordance with proven
standards of care without compromising public safety concerns inherent to
the BOP’s overall mission.
P6013.01 Health Services Quality Improvement — requires the BOP to
establish an outcome-based quality improvement system in the health care
programs at every BOP institution.
P6031.01 Patient Care — requires the BOP to effectively deliver medically
necessary health care to inmates in accordance with proven standards of
care without compromising public safety concerns inherent to the agency’s
overall mission. The statement requires every BOP institution to establish a
Utilization Review committee chaired by the Clinical Director to review:
•
•
•
•
•
•
•

outside medical, surgical, and dental procedures;
requests for specialist evaluations, in-house or escorted trips to the
specialist’s office;
requests for “Limited Medical Value” treatments and procedures;
retrospective review of all cases sent to the community hospital
during hours when no health care provider was on duty at the
institution;
case considerations for extraordinary care;
concurrent review of inpatients at community hospitals; and
other services the primary care provider or the Clinical Director
have recommended.

P6031.02 Inmate Copayment Program — provides that the BOP may
under certain circumstances charge an inmate under the BOP’s custody, a
fee for providing inmate health care services. However, inmates are not to
be denied access to necessary health care because of the inmate’s inability
to pay the copay fee.

P6270.01 Medical Designations and Referral Services for Federal
Prisoners — specifies procedures and criteria for transporting inmates who
require medical care. The Central Office Medical Designator, Office of
Medical Designations and Transportation, makes medical designations,
referrals, and denials based on:
•
•
•
•
•
•
•

urgency of need;
cost-effectiveness;
BOP institution capabilities;
expected service period, including recuperation;
current bed space availability;
security; and
consultation with BOP physicians at the sending and receiving
institutions.

P6090.01 Health Information Management — provides guidance for
ensuring that accurate and complete health records and qualified health
record practitioners are available for delivering health services.
P6400.02 Dental Services — requires the BOP to stabilize and maintain
the oral health of inmates in BOP institutions. Dental care is to be
conservative, providing necessary treatment for the greatest number of
inmates within available resources. Dental care should be provided to
inmates by health care providers, who provide quality care consistent with
professional standards.
P6340.04 Psychiatric Services — requires the BOP to provide psychiatric
services that address the physical, medical, psychological, social, vocational
and rehabilitative needs of inmates in the BOP’s custody who suffer from
mental illnesses and disorders.
P6360.01 Pharmacy Services — requires the BOP to provide inmates
access to quality, necessary, cost-effective pharmaceutical care.
P6370.01 Laboratory Services — provides guidance to ensure that
laboratory services will be regularly available to meet the needs of inmates
at all BOP institutions.
P6541.02 Over-the-Counter Medications — establishes a program
allowing inmates improved access to over-the-counter medications. The
statement provides that inmates may buy over-the-counter medications that
are available at the institution commissary. Inmates may also obtain overthe-counter medications at sick call if the inmate does not already have the
medication and if: (1) health services staff determine that the inmate has
86

an immediate medical need which must be addressed before his or her
regularly scheduled commissary visit, or (2) the inmate does not have funds
to purchase the medication at the commissary.
P6027.01 Health Care Provider Credential Verification, Privileges,
and Practice Agreement Program — provides that each Health Services
Unit will ensure that professional credentials for all health care providers
inside the institution are verified at the primary source (the issuer of the
credential). Providers include BOP staff, Public Health Services (PHS) staff,
part-time staff, contract and consultant staff, and those who provide a
diagnosis or treatment using tele-health.
P6021.04 Commissioned Officer Student Training Extern Program
(COSTEP) — encourages all BOP institutions to actively consider the
COSTEP Program of the PHS as a viable recruitment supplement. The
objectives of using COSTEPs are:
•

eligible COSTEP students will be recruited for health care work in
BOP facilities, and

•

some COSTEP students will return to careers in the BOP after
graduation.

P6190.03 Infectious Disease Management — provides that the BOP will
manage infectious disease in the confined environment of a correctional
setting through a comprehensive approach which includes testing,
appropriate treatment, prevention, education, and infection control
measures.
P6070.05 Birth Control, Pregnancy, Child Placement and Abortion —
establishes guidance for BOP institutions to provide inmates with medical
and social services related to birth control, pregnancy, child placement, and
abortion.
P6590.07 Alcohol Surveillance and Testing Program — requires the
BOP to maintain a surveillance program to deter and detect the illegal
introduction or use of alcohol in its institutions.
P6080.01 Autopsies — provides that the Warden of a BOP institution may
order an autopsy and related scientific or medical tests to be performed
when:
•

in the event of homicide, suicide, fatal illness or accident, or
unexplained death, the Warden determines that the autopsy or test
87

is necessary to detect a crime, maintain discipline, protect the
health or safety of other inmates, remedy official misconduct, or
defend the United States or its employees from civil liability arising
from the administration of the facility; or
•

the Warden obtains the written consent of a person (coroner, nextof-kin, the decedent’s consent in the case of tissue removed for
transplanting) authorized to permit the autopsy or post-mortem
operation under the law of the State in which the facility is located.

P6311.04 Plastic Surgery and Identification Records — provides that
the BOP does not ordinarily perform plastic surgery on inmates to correct
preexisting disfigurements (including tattoos) on any part of the body. In
circumstances where plastic surgery is a component of a presently medically
necessary standard of treatment (for example, part of the treatment for
facial lacerations or for mastectomies due to cancer) or it is necessary for
the good order and security of the institution, the necessary surgery may be
performed.
6010.01 Psychiatric Treatment and Medications, Administrative
Safeguards for — provides guidelines for providing administrative
safeguards for psychiatric treatment and medication.
P6060.08 Urine Surveillance and Narcotic Identification — requires
that BOP institutions must establish programs of urine testing for drug use
to monitor specific groups or individual inmates who are considered as high
risk for drug use, such as those in community activities, those with a history
of drug use, and those inmates specifically suspected of drug use.

APPENDIX VII
Results of the OIG’s Testing of the Provision
of Medical Care at BOP Institutions29
United States Penitentiary – Atlanta
Medical Service Tested

Inmates
Tested

Yes

1. Inmate medical history provided
by inmate at intake

191

99%

2. Medical assessment completed
by medical practitioner at intake

191

96%

3. New inmate tested for
tuberculosis or previous test for
transferred inmate confirmed,
within 48 hours of intake

191

97%

4. Inmate received a rapid plasma
regain test during intake screening
to test for syphilis

94%

5. Female inmate tested for
Chlamydia

Test not applicable for any inmates at this facility

6. Female inmate received a
measles/ mumps/rubella vaccine

Test not applicable for any inmates at this facility

7. Inmate received a complete
physical within 14 days of intake

191

8. Inmate received a pneumococcal
vaccine

9. Inmate received an annual
influenza vaccine

10. Inmate born after 1956 received
a measles/ mumps/ rubella vaccine

167

11. Inmate received a tetanus
vaccine in the last 10 years

191

94%

90%
83%
7%

17%
93%

94%

12. Inmate received a hepatitis A
vaccine

13. Inmate received a hepatitis B
test or vaccine

96%

14. Inmate received a hepatitis C
test

98%

15. Inmate received an HIV-1 test

100%

16. Inmate received an HIV-2 test

100%

17. Inmate received a tuberculosis
test in the past year

171

18. Inmate received a chronic care
evaluation in the last 6 months

97%

99%
95%

Some percentages in the charts total less than 100 percent because
documentation was not available to determine if the test was performed for some inmates.

1%
3%

United States Penitentiary – Atlanta

Medical Service Tested

Inmates
Tested

19. Inmate received a cholesterol
check in the last 5 years

135

20. Inmate received a cardiovascular
risk calculation in the last 5 years

21. Inmate received a fasting plasma
glucose test in the last 3 years

Yes

29%

70%
100%
34%

45%

22. Inmate received a current blood
pressure check

190

23. Inmate received a current body
mass index calculation

190 4%

95%

5%
96%

24. Inmate received a fecal occult
blood test

25. Inmate received a vision
screening test

100%

26. Inmate received a hearing
screening test

100%

27. Inmate received an abdominal
ultrasound test

Test not applicable for any inmates at this facility

28. Female inmate received a
papanicolaou test (PAP smear)

Test not applicable for any inmates at this facility

29. Female inmate received a
current mammogram

Test not applicable for any inmates at this facility

30. Female inmate received a bone
density screening test

Test not applicable for any inmates at this facility

12%

88%

United States Penitentiary – Lee

Medical Service Tested
1. Inmate medical history provided
by inmate at intake

Yes

Inmates
Tested
133

99%

2. Medical assessment completed
by medical practitioner at intake

133

99%

3. New inmate tested for
tuberculosis or previous test for
transferred inmate confirmed,
within 48 hours of intake

133

99%

91%

4. Inmate received a rapid plasma
regain test during intake screening
to test for syphilis
5. Female inmate tested for
Chlamydia

Test not applicable for any inmates at this facility

6. Female inmate received a
measles/ mumps/rubella vaccine

Test not applicable for any inmates at this facility

7. Inmate received a complete
physical within 14 days of intake

133

90%

8. Inmate received a pneumococcal
vaccine

50%

9. Inmate received an annual
influenza vaccine

50%

10. Inmate born after 1956 received
a measles/ mumps/ rubella vaccine

127

11. Inmate received a tetanus
vaccine in the last 10 years

133

27%

72%

12. Inmate received a hepatitis A
vaccine

26%

72%

13. Inmate received a hepatitis B
test or vaccine

14. Inmate received a hepatitis C
test

73%

23%

15. Inmate received an HIV-1 test

74%

25%

16. Inmate received an HIV-2 test

17. Inmate received a tuberculosis
test in the past year

105

18. Inmate received a chronic care
evaluation in the last 6 months

99%

68%

30%

75%
96%
86%

3%
10%

United States Penitentiary – Lee

Medical Service Tested
19. Inmate received a cholesterol
check in the last 5 years

20. Inmate received a cardiovascular
risk calculation in the last 5 years

21. Inmate received a fasting plasma
glucose test in the last 3 years

22. Inmate received a current blood
pressure check

133

23. Inmate received a current body
mass index calculation

133 1%

24. Inmate received a fecal occult
blood test

Yes

Inmates
Tested

68%

30%
98%

40%

60%
90%

10%
99%

29%

71%

25. Inmate received a vision
screening test

26. Inmate received a hearing
screening test

27. Inmate received an abdominal
ultrasound test

Test not applicable for any inmates at this facility

28. Female inmate received a
papanicolaou test (PAP smear)

Test not applicable for any inmates at this facility

29. Female inmate received a
current mammogram

Test not applicable for any inmates at this facility

30. Female inmate received a bone
density screening test

Test not applicable for any inmates at this facility

Test not applicable for any inmates at this facility
100%

Federal Correctional Complex – Terra Haute
Medical Service Tested

Inmates
Tested

Yes

1. Inmate medical history provided
by inmate at intake

248

100%

2. Medical assessment completed by
medical practitioner at intake

248

100%

3. New inmate tested for
tuberculosis or previous test for
transferred inmate confirmed,
within 48 hours of intake

248

4. Inmate received a rapid plasma
regain test during intake screening
to test for syphilis
5. Female inmate tested for
Chlamydia

99%

98%

48
0

Test not applicable for any inmates at this facility

6. Female inmate received a
measles/ mumps/rubella vaccine

Test not applicable for any inmates at this facility

7. Inmate received a complete
physical within 14 days of intake

248

98%

8. Inmate received a pneumococcal
vaccine

9. Inmate received an annual
influenza vaccine

10. Inmate born after 1956 received
a measles/ mumps/ rubella vaccine

223

11. Inmate received a tetanus
vaccine every 10 years

248

91%

86%

14%

99%

1%
40%

60%

12. Inmate received a hepatitis A
vaccine

13. Inmate received a hepatitis B
test or vaccine

91%

14. Inmate received a hepatitis C
test

96%

15. Inmate received an HIV-1 test

99%

16. Inmate received an HIV-2 test

99%

17. Inmate received a tuberculosis
test in the past year

215

18. Inmate received a chronic care
evaluation in the last 6 months

102

48%

52%

98%
100%

9%
4%

Federal Correctional Complex – Terra Haute

Medical Service Tested
19. Inmate received a cholesterol
check in the last 5 years

20. Inmate received a cardiovascular
risk calculation in the last 5 years

187
98

87%

13%

18%

82%

21. Inmate received a fasting plasma
120
glucose test in the last 3 years
22. Inmate received a current blood
pressure check

248

23. Inmate received a current body
mass index calculation

248

24. Inmate received a fecal occult
blood test

25. Inmate received a vision
screening test

26. Inmate received a hearing
screening test

Yes

Inmates
Tested

95%

98%
36%

2%
64%

80%

20%

100%
78%

22%

27. Inmate received an abdominal
ultrasound test

28. Female inmate received a
papanicolaou test (PAP smear)

Test not applicable for any inmates at this facility

29. Female inmate received a
current mammogram

Test not applicable for any inmates at this facility

30. Female inmate received a bone
density screening test

Test not applicable for any inmates at this facility

100%

Federal Medical Center – Carswell
Medical Service Tested
1. Inmate medical history provided
by inmate at intake

Inmates
Tested

Yes

127

100%

2. Medical assessment completed
by medical practitioner at intake

127

100%

3. New inmate tested for
tuberculosis or previous test for
transferred inmate confirmed,
within 48 hours of intake

127

100%

4. Inmate received rapid plasma
regain test during intake screening
to test for syphilis
5. Female inmate tested for
Chlamydia

91%

126
24

6. Female inmate received a
measles/ mumps/rubella vaccine

116

7. Inmate received a complete
physical within 14 days of intake

127

8. Inmate received a pneumococcal
vaccine

9. Inmate received an annual
influenza vaccine

10. Inmate born after 1956 received
a measles/ mumps/ rubella vaccine

117

11. Inmate received a tetanus
vaccine in the last 10 years

127

38%

62%
80%

19%
100%
50%

50%
59%

41%

80%

20%

80%

12. Inmate received a hepatitis A
vaccine

13. Inmate received a hepatitis B
test or vaccine

14. Inmate received a hepatitis C
test

15. Inmate received an HIV-1 test

92%

16. Inmate received an HIV-2 test

100%

17. Inmate received a tuberculosis
test in the past year

111

100%

18. Inmate received a chronic care
evaluation in the last 6 months

100%

24%

19%
76%

97%
84%

3%
16%
8%

Federal Medical Center – Carswell

Medical Service Tested
19. Inmate received a cholesterol
check in the last 5 years

20. Inmate received a cardiovascular
risk calculation in the last 5 years

21. Inmate received a fasting plasma
glucose test in the last 3 years

22. Inmate received a current blood
pressure check

127

23. Inmate received a current body
mass index calculation

127

24. Inmate received a fecal occult
blood test

25. Inmate received a vision
screening test

26. Inmate received a hearing
screening test

27. Inmate received an abdominal
ultrasound test

28. Female inmate received a
papanicolaou test (PAP smear)
29. Female inmate received a current
mammogram
30. Female inmate received a bone
density screening test

Yes

Inmates
Tested

92%
2%

98%
7%

93%
100%
23%

77%
48%

52%
96%

4%
80%

20%

Test not applicable for any inmates at this facility

123

99%

100%

50%

Federal Correctional Complex – Victorville
Medical Service Tested

Inmates
Tested

Yes

1. Inmate medical history provided
by inmate at intake

345

2. Medical assessment completed by
medical practitioner at intake

345

99%

3. New inmate tested for
tuberculosis or previous test for
transferred inmate confirmed,
within 48 hours of intake

344

100%

4. Inmate received rapid plasma
reagin test during intake screening
to test for syphilis
5. Female inmate tested for
Chlamydia

99%

1%
1%

91%

137
1

100%

6. Female inmate received a
measles/ mumps/rubella vaccine

83%

7. Inmate received a complete
physical within 14 days of intake

345

92%

8. Inmate received a pneumococcal
vaccine

60%

36%

9. Inmate received an annual
influenza vaccine

61%

38%

10. Inmate born after 1956 received
a measles/ mumps/ rubella vaccine

298

11. Inmate received a tetanus
vaccine every 10 years

345

12. Inmate received a hepatitis A
vaccine

17%
5%

94%
32%

68%
79%

19%

89%

14. Inmate received a hepatitis C
test

93%

15. Inmate received an HIV-1 test

114

95%

16. Inmate received an HIV-2 test

17. Inmate received a tuberculosis
test in the past year

267

18. Inmate received a chronic care
evaluation in the last 6 months

100%
98%
99%

2%
1%

Federal Correctional Complex – Victorville

Medical Service Tested
19. Inmate received a cholesterol
check in the last 5 years

215

20. Inmate received a cardiovascular
risk calculation in the last 5 years

131 2%

21. Inmate received a fasting plasma
glucose test in the last 3 years

64%

345

23. Inmate received a current body
mass index calculation

338

36%
98%

22. Inmate received a current blood
pressure check

Yes

Inmates
Tested

95%

96%

100%

24. Inmate received a fecal occult
blood test

25. Inmate received a vision
screening test

26. Inmate received a hearing
screening test

27. Inmate received an abdominal
ultrasound test

28. Female inmate received a
papanicolaou test (PAP smear)

29. Female inmate received a current
mammogram

100%

30. Female inmate received a bone
density screening test

100%

20%

80%
50%

50%

33%

67%
100%
95%

APPENDIX VIII
The BOP’s Health Care Performance Measures
Description
Clinical Management
of Hypertension

Clinical Management
of Lipid Level

Clinical Management
of Diabetes – HbA1C
Level

Clinical Management
of HIV/ Ribonucleic
Acid Level

Numerator
Number of
hypertensive patients
on medication
evaluated this
reporting quarter with
a blood pressure
reading of less
<140/< 90
millimeters of mercury
Number of patients on
lipid reduction
medication, with a
history of
cardiovascular risk or
two cardiac risk
factors, with a low
density lipoprotein
level < 100 milligrams
reported this reporting
quarter
Number of diabetic
patients on insulin or
oral medication with
an HbA1C level
measured 8% or less,
as a result of a test
this reporting quarter
Number of inmates on
antiretroviral therapy
with HIV/ Ribonucleic
Acid levels < 50
cps/ml, as confirmed
by ultra-sensitive
method this reporting
quarter

Denominator
Number of patients
being treated for
hypertension with
medication, for a
minimum of 6 months,
who are evaluated this
reporting quarter

Target
Percentage

2004 - 70%
2005 – 70%
2006 – 70%
2007 – 70%

Number of patients on
lipid reduction
medication for a
minimum of 6 months,
who have lipids
measured this
reporting quarter and
meet requirements
listed in the
numerator statement

2004 - 65%
2005 – 50%
2006 – 50%
2007 – 65%

Number of diabetic
patients on insulin or
oral medication for a
minimum of 6 months
with HbA1C level
measured this
reporting quarter
Number of inmates on
antiretroviral therapy
with known HIV/
Ribonucleic Acid
standard level of <
400 cps/ml who have
had the ultra-sensitive
method test this
reporting quarter < 50
cps/ml, as confirmed
by ultra-sensitive
method this reporting
quarter

2004 - 65%
2005 – 65%
2006 – 65%
2007 – 65%

2004 - 60%
2005 – 60%
2006 – 60%
2007 – 85%

Description
Completion of
Isoniazid Treatment

Numerator
Number of inmates on
treatment for Latent
Tuberculosis Infection
who have completed
bi-weekly isoniazid
therapy during this
reporting quarter

Asthma-related
Hospitalization or
Mortality

Number of patients
diagnosed with
asthma, who are
taking chronic asthma
medication, and who
were not hospitalized,
or did not expire from
asthma this reporting
quarter
Number of females
screened by
mammography this
reporting period

Breast Cancer
Screening

Cervical Cancer
Screening
Pregnancy Testing at
Intake

Number of female
patients who received
screening by PAP this
reporting period
Number of new intake
females tested for
pregnancy this
reporting period

100

Denominator
Number of inmates
previously started on
treatment for Latent
Tuberculosis Infection
who should have
completed treatment
within this reporting
quarter
Number of patients
diagnosed with
asthma, who are
taking chronic asthma
medication, and who
were in the institution
this reporting quarter
Number of females
who require
mammography
screening this
reporting period
Number of female
patients who would
require screening by
PAP
Number of new female
intakes (premenopausal) arriving
in the institution this
reporting period

Target
Percentage
2005 – 90%
2006 – 90%
2007 – 90%

2005 – 100%
2006 – 100%
2007 – 98%

2004 - 50%
2005 – 50%
2006 – 50%
2007 – 50%
2004 - 50%
2005 – 50%
2006 – 50%
2007 – 50%
2004 - 90%
2005 – 90%
2006 – 90%
2007 – 90%

APPENDIX IX
Types of BOP Institutions
The BOP operates institutions at five different security levels in order
to confine offenders in an appropriate manner. The security levels are based
on such features as the presence of external patrols, towers, security
barriers, or detection devices; the type of housing within the institution;
internal security features; and the staff-to-inmate ratio. Each institution is
given a security designation of either minimum, low, medium, high, or
administrative.
Minimum Security
Minimum security institutions, also known as Federal Prison Camps
(FPC), have dormitory housing, a relatively low staff-to-inmate ratio, and
limited or no perimeter fencing. These institutions are work-oriented and
program-oriented. Many of these institutions are located adjacent to larger
institutions or on military bases, where inmates help serve the labor needs
of the larger institution or base.
Low Security
Low security Federal Correctional Institutions (FCI) have doublefenced perimeters, mostly dormitory or cubicle housing, and strong work
and program components. The staff-to-inmate ratio in these institutions is
higher than in minimum security facilities.
Medium Security
Medium security FCIs have strengthened perimeters often with double
fences and electronic detection systems, mostly cell-type housing, a wide
variety of work and treatment programs, an even higher staff-to-inmate
ratio than low security FCIs, and even greater internal controls.
High Security
High security institutions, also known as United States Penitentiaries
(USP), have highly-secured perimeters featuring walls or reinforced fences,
multiple-occupant and single-occupant cell housing, the highest staff-toinmate ratio, and close control of inmate movement.

101

Correctional Complexes
A number of BOP institutions belong to Federal Correctional Complexes
(FCC). At FCCs, institutions with different missions and security levels are
located in close proximity to one another. FCCs increase efficiency through
the sharing of services, enable staff to gain experience at institutions that
have many security levels, and enhance emergency preparedness by having
additional resources within close proximity.
Administrative
Administrative facilities are institutions with special missions, such as
the detention of pretrial offenders; the treatment of inmates with serious or
chronic medical problems; or the containment of extremely dangerous,
violent, or escape-prone inmates. Administrative facilities include
Metropolitan Correctional Centers (MCC), Metropolitan Detention Centers
(MDC), Federal Detention Centers (FDC), and Federal Medical Centers
(FMC), as well as the Federal Transfer Center (FTC), the Medical Center for
Federal Prisoners (MCFP), and the Administrative-Maximum (ADX) USP.
Administrative facilities are capable of holding inmates in all security
categories.
Satellite Camps
A number of BOP institutions have a small, minimum-security camp adjacent
to the main facility. These camps, often referred to as satellite camps,
provide inmate labor to the main institution and to off-site work programs.
FCI Memphis has a non-adjacent camp that serves similar needs.
Satellite Low Security
The BOP has two FCIs that have a small, low-security satellite facility
adjacent to the main institution. The BOP also has one FCI that has a lowsecurity facility affiliated with, but not adjacent to, the main institution.

102

APPENDIX X
Department of Justice, Office of the Inspector General
Audits of BOP Medical Contracts from
August 2004 through March 2007
From August 2004 through March 2007, the OIG issued nine audit
reports on BOP contracts for medical services. The OIG reported on major
internal control deficiencies for eight of the nine medical services contract
audits. Deficiencies included weak procedures or processes for calculating
discounts, reviewing and verifying invoices and billings, paying bills, and
managing the overall administration of the contracts. As of November 2007,
the BOP’s Program Review Division said that corrective actions had been
implemented for all recommendations in seven of the nine contract audits.
For the other two audits (Correctional Medical Services at Fort Dix, New
Jersey and Medical Development International at FCC Butner, North
Carolina), the BOP agreed to take corrective actions on the OIG’s
recommendations, and those actions were either completed or in progress as
of November 2007. The OIG’s findings and recommendations for the nine
audits are summarized below.
Parkview Medical Center
In an August 2004 audit report on the BOP’s contract with the
Parkview Medical Center (PMC), the OIG reported on the purchase of
inpatient and outpatient facility and physician services for inmates at the
Federal Correctional Complex in Florence, Colorado.30 The OIG found that:
(1) PMC did not provide documentation to support billings for pharmacy
items, (2) PMC billed for prescription drugs that were not on the BOP’s
approved formulary, (3) PMC did not provide the required Summary Paid
Billing Analysis Reports to the BOP each quarter, and (4) the BOP could
improve contract administration by better analyzing contract modifications
prior to the acceptance of new terms.
The OIG recommended the BOP:
•

remedy $424,638 in questioned costs paid to the PMC for
unsupported pharmacy items,

Department of Justice, Office of the Inspector General, The Bureau of Prisons’
Contract with the Parkview Medical Center for the Acquisition of Medical Services (J40604c030), Audit Report GR-60-04-008 (August 2004).

103

•

remedy the $94,774 in questioned costs paid to the PMC for drugs
not listed in an applicable BOP formulary,

•

implement controls to ensure the PMC submits the Quarterly
Summary Paid Billing Analysis Report on time, and

•

analyze future contract modifications to accurately determine the
effect on the contract prior to acceptance.

Correctional Medical Services
In a September 2004 report on the BOP’s contract with Correctional
Medical Services (CMS), the OIG reported on the acquisition of
comprehensive medical services for inmates at the FCI facility at Fort Dix,
New Jersey.31
The OIG found that: (1) CMS did not schedule and provide outpatient
institutional and physician services within the time allowed by the contract
after receiving a request from the FCI, (2) the BOP had obtained services
outside the contract because CMS could not provide agreed-upon services,
(3) CMS did not provide a Quality Assurance and Improvement Program and
quarterly Summary Paid Billing Analysis Reports to the BOP, (4) CMS did not
provide replacement non-Medicare personnel in a timely manner, (5) CMS
charged for duplicative services and for services cancelled by the BOP, and
(6) CMS billed for Magnetic Resonance Imaging (MRI) services after the MRI
portion of the contract had expired.
The OIG recommended the BOP:
•

ensure that CMS provides outpatient institutional and physician
services in accordance with the terms and conditions of the
contract,

•

remedy the $9,321,106 paid to the CMS because the government
awarded the contract based on services in the CMS’s proposal that
the CMS did not have the capability to deliver,

•

acquire biomedical services from the CMS at the prices set forth in
the contract,

Department of Justice, Office of the Inspector General, Correctional Medical
Services’ Compliance with the Federal Bureau of Prisons’ Contract J21451c-009, Audit
Report GR-70-04-009 (September 2004).

104

•

ensure that the CMS provides a Quality Assurance and
Improvement Program and the Summary Paid Billing Analysis
Reports in accordance with the contract,

•

remedy the $1,600 in duplicative orthopedic examination costs paid
to the CMS,
remedy the $7,096 paid to the CMS for services cancelled by the
BOP, and

•
•

remedy the $31,620 that the CMS billed for MRI services after the
MRI portion of the contract had expired.

Medical Development International at the United States Penitentiary
and Federal Prison Camp in Leavenworth, Kansas
In a February 2005 report on the BOP’s contract with Medical
Development International (MDI), the OIG reported on the acquisition of
medical services for the United States Penitentiary and Federal Prison Camp
in Leavenworth, Kansas.32 The OIG found that: (1) MDI did not obtain
certification of residency forms from all medical providers as required by the
contract, (2) the BOP Contracting Officer’s Technical Representative did not
submit contractor monitoring reports on a quarterly basis as required, and
(3) the BOP Contracting Officer’s Technical Representative did not use the
BOP’s rating guidelines on monitoring reports submitted.
The OIG recommended the BOP:
•

obtain the required residency certification forms for all medical
personnel who provide off-site care for inmates, and

•

require the Contracting Officer’s Technical Representative to submit
contractor monitoring reports in a timely manner and use the rating
guidelines when evaluating the contractor’s performance.

Wayne Memorial Hospital
In an April 2005 report on the BOP’s contract with the Wayne Memorial
Hospital (WMH), the OIG reported on the acquisition of comprehensive

Department of Justice, Office of the Inspector General, The Federal Bureau of
Prisons’ Contract with Medical Development International for the Acquisition of Medical
Services at its Leavenworth, Kansas Facilities (Contract No. DJB40804003), Audit
Report GR-60-05-003 (February 2005).

105

inmate medical services provided by WMH to inmates at FCI, Jesup.33 The
OIG found that: (1) WMH did not always provide Inmate Discharge
Summary Reports in a timely manner, (2) FCI Jesup obtained medical
services from providers outside the contract when the contractor was able to
provide some of those services, (3) WMH billed and was paid for medical
services that were calculated using incorrect billing practices, (4) WMH billed
and was paid for medical services that were not supported with adequate
documentation, and (5) FCI Jesup paid for medical services with billings that
were unsupported.
The OIG recommended the BOP:
•

ensure the contract accurately specifies services that are to be
provided and other specific terms and conditions of the contract,

•

ensure the contractor provides Inmate Discharge Summary Reports
in a timely manner,

•

remedy more than $76,000 charged to the contract because the
contractor used incorrect rates when it prepared the billing
statements or because adequate documentation was not
maintained to support the billing statements, and

•

ensure the FCI strengthens its controls for reviewing and processing
invoices for payment.

Salem Community Hospital
In a June 2005 report on the BOP’s Contract with the Salem
Community Hospital, the OIG reported on the acquisition of comprehensive
medical services for inmates at FCI Elkton facility in Salem, Ohio.34 The OIG
found that: (1) the Salem Community Hospital overcharged for services it
provided during the first 8 months of the contract by using incorrect rates to
calculate invoice discounts, (2) the Salem Community Hospital made
additional errors in the discounts charged and in the time charges for

Department of Justice, Office of the Inspector General, The Federal Bureau of
Prisons’ Medical Services Contract with Wayne Memorial Hospital, Jesup, Georgia (Contract
J30703c-020), Audit Report GR-40-05-006 (April 2005).
34

Department of Justice, Office of the Inspector General, The Federal Bureau of
Prisons’ Contract Number DJB21602-004 with Salem Community Hospital in Salem, Ohio,
Audit Report GR-50-05-012 (June 2005).

106

operating and recovery room services, and (3) FCI Elkton had no formal
written procedures for reviewing and verifying the accuracy of its invoices.
The OIG recommended the BOP:
•

direct FCI Elkton to remedy $744 in overcharges paid to Salem
Community Hospital,

•

direct FCI Elkton to ensure the Salem Community Hospital
implemented control procedures to ensure charges and discounts
on invoices were correctly calculated,

•

direct FCI Elkton to review and revise its review procedures to
ensure invoices approved for payment were accurate, and

•

direct FCI Elkton to formalize its invoice review procedures in
writing.

Hospital Corporation of America-HealthONE
In a March 2006 report on the Medical Services contract with the
Hospital Corporation of America-HealthONE, L.L.C. (HealthONE), the OIG
reported on the acquisition of comprehensive medical services for inmates at
the FCI Englewood facility in Littleton, Colorado.35 The OIG found that:
(1) HealthONE did not submit quarterly Summary Paid Billing Analysis
Reports to FCI Englewood as required, (2) the BOP Contracting Officer’s
Technical Representative could not provide documentation supporting the
information reported in the quarterly contractor performance reports,
(3) FCI Englewood had no written procedures for monitoring and reviewing
of the contractor’s billing process, and (4) FCI Englewood had no
documentation supporting a review process for exercising each option of the
contract.
The OIG recommended the BOP:
•

document the criteria used to assess contractor performance and
document the quantitative results of the evaluations,

•

prepare quarterly statistical reports as required,

Department of Justice, Office of the Inspector General, The Federal Bureau of
Prisons’ Contract with Hospital Corporation of America-HealthONE, L.L.C., Contract No.
J40303c-146, Audit Report GR-60-06-006 (March 2006).

107

•

document procedures for verifying the accuracy of the invoices for
supplies and services, and

•

ensure the contractor submitted quarterly Summary Paid Billing
Analysis Reports.

University of Massachusetts Medical School and the UMass Memorial
Health Care, Inc.
In a March 2006 report on the medical services contract with the
University of Massachusetts Medical School and the UMass Memorial Health
Care, Inc. (collectively UMass), the OIG reported on the contractor’s
compliance with the contract for providing medical services to inmates at
FMC Devens in Ayer, Massachusetts.36 The OIG found that: (1) UMass did
not consistently provide services at the location most advantageous to the
government, (2) UMass lacked a detailed electronic database containing
individual charges which prevented tests of the charges, (3) the FMC was
not able to independently verify contract charges based on the Medicare
hospital inpatient prospective payment system, and (4) the contract
contained terms and requirements that were unreasonable or imprecisely
written and were ignored by both parties.
The OIG recommended the BOP:
•

require the contractor to provide detailed data on all contract
charges electronically and use this data to analyze and manage
contractor performance and costs;

•

develop and implement management tools to ensure services were
consistently provided at the location most advantageous to the
government;

•

develop the capability to independently verify contractor charges for
inpatient hospital services based on the Medicare inpatient
prospective payment system; and

•

improve contract administration by requiring the contractor to
adhere to all terms and conditions of the contract, and when

Department of Justice, Office of the Inspector General, The University of
Massachusetts Medical School and UMass Memorial Health Care, Incorporated’s Compliance
with the Federal Bureau of Prisons’ Contract DJB20507032, Audit Report GR-70-06-006
(March 2006).

108

appropriate, amend the contract to ensure all contract terms were
reasonable, clear, and enforceable.
John C. Lincoln Health Network
In an August 2006 report on the medical services contract with the
John C. Lincoln Health Network, the OIG reported on the acquisition of
hospital facility services for the United States Penitentiary and the Federal
Prison Camp in Phoenix, Arizona (FCI Phoenix).37 The OIG found that:
(1) FCI Phoenix had not formalized in writing the procedures or policies for
monitoring and reviewing contractor billings, (2) FCI Phoenix’s payments to
the contractor were not processed in a manner consistent with the Prompt
Payments Act, (3) the BOP Contracting Officer’s Technical Representative did
not maintain adequate supporting documentation for performance reports,
and (4) the BOP Contracting Officer did not review the performance reports
in a timely manner.
The OIG recommended the BOP:
•

finalize draft procedures for monitoring contractor billing and
performance,

•

identify procedural hindrances to full compliance with the Prompt
Payments Act,

•

implement new procedures for documenting supporting justification
for evaluative rankings in performance reports,

•

implement a policy to define and require a timely review of
performance reports by the Contracting Officer, and

•

ensure that the Contracting Officer either maintained or had
accessed to a comprehensive listing of all contract expenditures to
assist in contract monitoring.

Medical Development International at FCC Butner and FMC Butner
In a March 2007 report on another BOP contract with MDI, the OIG
reported on the acquisition of comprehensive medical services provided to
37

Department of Justice, Office of the Inspector General, The Federal Bureau of
Prisons’ Contract with the John C. Lincoln Health Network, Contract No. DJB60803144, Audit
Report GR-60-06-009 (August 2006).

109

inmates at FCC Butner and FMC Butner in Butner, North Carolina.38 The OIG
found that: (1) the BOP’s procedures for reviewing and approving billing
rates were weak; (2) MDI’s invoices contained transactions that were not
within the service period being billed; (3) MDI billed the BOP for some
transactions at a rate higher than specified in the contract; (4) MDI billed
the BOP for some services not covered by the contract; (5) the BOP did not
sign off on the timesheets submitted by the contractor; (6) MDI submitted
timesheets that were either miscalculated, overstated, understated or not
supported; (7) MDI billed for transactions where the hours billed were
greater than the hours recorded in the institutions’ sign-in and out logs; (8)
MDI billed for transactions where the hours billed were for MDI contractors
whose names did not appear in the sign-in and sign-out logs; and (9) MDI
did not provide adequate support for billing statements for “on call” services
provided under the contract.
The OIG recommended the BOP:
•

remedy the $2,428,345 in questioned costs;

•

implement various internal controls to ensure the BOP paid for
services allowed by the contract, actually provided by the
contractor, and at rates contained in the contract;

•

improve contract administration to ensure the contractor adhered to
all terms of the contract; and

•

include specific terms and requirements for the billing of personnel
services in the pricing and billing sections for future medical
services contracts.

Department of Justice, Office of the Inspector General, The Bureau of Prisons’
Management of the Medical Services Contract with Medical Development International,
Butner, North Carolina, Contract No. DJB10611-00, Audit Report Number GR-40-07-003
(March 2007).

110

APPENDIX XI
The BOP’s Response to the Draft Audit Report

111

112

113

114

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APPENDIX XII
Office of the Inspector General, Audit Division, Analysis
and Summary of Actions Necessary to Close the Report
We provided the draft report to the BOP for review and requested
written comments. The BOP’s written response is included as Appendix XI of
this report. The BOP agreed with all of our recommendations and proposed
corrective action appropriate to resolve the recommendations. However, in
its only comment on the extensive content of the draft report, the BOP
objected to a sentence on page 55 reading “The BOP institutions did not
provide necessary medical care to inmates.” This sentence was included in
the draft report as a very brief summary of Finding 1, which is also
referenced on page 55. In response to the BOP’s statement, we reviewed
our draft report’s language on page 55 and revised it to summarize more
precisely Finding 1. The revised statement on 55 now reads “The BOP’s
institutions did not always provide recommended preventative medical
services to inmates.”
We provide below our analysis of the BOP’s response to the
recommendations.
1.

Resolved. We recommended the BOP establish procedures for
collecting and evaluating data for each current and future health care
initiative to assess whether individual initiatives are cost-effective and
producing the desired results. The BOP agreed and stated that it will
establish protocols for collecting and evaluating data. The
recommendation can be closed when we review the procedures the BOP
establishes to assess the cost effectiveness of its initiatives.

Resolved. We recommended the BOP review the medical services that
the OIG and the BOP’s Program Review Division identified as not always
provided to inmates and determine whether those medical services are
necessary, or whether the medical service requirement should be
removed from the Clinical Practice Guidelines. The BOP agreed with the
recommendation. It stated that in January 2008, it reviewed all of its
Clinical Practice Guidelines and identified certain guidelines for revision.
The BOP also stated that it will highlight its Program Review Division’s
quarterly reports in on-line training sessions, with the first session
taking place in April 2008. We request that the BOP provide us with a
list of guidelines identified for revision and the time frame for
accomplishing the revisions. The recommendation can be closed when
we review revisions to the Clinical Practice Guidelines.

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Resolved. We recommended the BOP issue clarifying guidance to the
institutions regarding the medical services that the BOP decides are
necessary for BOP medical providers to perform. The BOP agreed and
stated that by April 2008 it will issue guidance to its institutions
underscoring the importance of the Clinical Practice Guidelines. The
recommendation can be closed when we review the BOP’s clarifying
guidance.

Resolved. We recommended the BOP strengthen management controls
to ensure proper administration of BOP medical contracts by providing
guidance and procedures to all BOP institutions. The BOP agreed and
stated that by April 2008 it will issue guidance to all Bureau Contracting
Officers and Health Services Administrators regarding medical contract
administration procedures. The recommendation can be closed when
we review the BOP’s guidance.

Resolved. We recommended the BOP develop a process to use the
program summary reports prepared by the Program Review Division to
develop or clarify agency-wide guidance on systemic deficiencies found
during program reviews. The BOP agreed and stated that it will issue
guidance regarding systemic deficiencies found during program reviews
through periodic on-line training sessions, the first of which will begin in
May 2008. The recommendation can be closed when we receive
documentation showing the BOP has developed a process and issued
guidance.

Resolved. We recommended the BOP ensure initial privileges, practice
agreements, or protocols are established for all practitioners, as
applicable. The BOP agreed and stated that by April 1, 2008, it will
issue guidance clarifying to institutions the importance of ensuring that
applicable privileges, practice agreements, protocols, and peer reviews
are handled in a timely manner, and the potential consequences of
failure to do so. While we agree that clarified guidance is, in part,
appropriate to address this recommendation, it is not clear to us how
the issuance of clarified guidance alone will ensure the establishment of
privileges, practice agreements, and protocols. We believe that
ensuring the establishment of these items requires a mechanism such
as testing during program reviews, submission of periodic certification
statements, submission of periodic reports by institutions, or some other
appropriate verification technique. We request that the BOP explain
how the implementation of the clarified guidance will be verified. The

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recommendation can be closed when we review the BOP’s clarifying
guidance and documentation for the verification mechanism.
7.

Resolved. We recommended that the BOP ensure privileges, practice
agreements, and protocols are reevaluated and renewed in a timely
manner. The BOP agreed and stated that the guidance it plans in
response to Recommendation 6 will also address this recommendation.
As with Recommendation 6, we agree that clarified guidance is, in part,
appropriate to address this recommendation, but it is not clear to us
how the issuance of clarified guidance alone will ensure that privileges,
practice agreements, and protocols are reevaluated and renewed in a
timely manner. We believe a verification technique also is needed for
this recommendation, and we request that the BOP explain how the
implementation of the clarified guidance will be verified. The
recommendation can be closed when we review the BOP’s clarifying
guidance and documentation for the verification mechanism.

Resolved. We recommended the BOP ensure that practitioners are not
allowed to practice medicine in BOP institutions without current
privileges, practice agreements, or protocols. The BOP agreed and
stated that the guidance it plans in response to Recommendation 6 will
also address this recommendation. As with Recommendation 6, we
agree that clarified guidance is, in part, appropriate to address this
recommendation, but it is not clear to us how the issuance of clarified
guidance alone will ensure that practitioners are not allowed to practice
absent current privileges, practice agreements, or protocols. We believe
a verification technique also is needed for this recommendation, and we
request that the BOP explain how the implementation of the clarified
guidance will be verified. The recommendation can be closed when we
review the BOP’s clarifying guidance and documentation for the
verification mechanism.

Resolved. We recommended the BOP ensure that peer reviews of all
providers are performed within the prescribed time frames. The BOP
agreed and stated that the guidance it plans in response to
Recommendation 6 will also address this recommendation. As with
Recommendation 6, we agree that clarified guidance is, in part,
appropriate to address this recommendation, but it is not clear to us
how the issuance of clarified guidance alone will ensure that peer
reviews are performed within the prescribed time frames. We believe a
verification technique also is needed for this recommendation, and we
request that the BOP explain how the implementation of the clarified
guidance will be verified. The recommendation can be closed when we

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review the BOP’s clarifying guidance and documentation for the
verification mechanism.
10. Resolved. We recommended to the BOP that, until the training
program on accumulating and reporting performance data is
implemented, it issue guidance to all institutions on how to accumulate
and report data for the health care performance measures to ensure
consistency in the way institutions collect and report performance data.
We also recommended that, once the training program is fully
developed, the BOP ensure that appropriate institution staff receives the
training. The BOP agreed and stated that by May 1, 2008, it will issue
guidance to all institutions on how to accumulate and report data for the
health care performance measures to ensure consistency in the way
institutions collect and report performance data. Data collections and
reporting will also be addressed in on-line training. The
recommendation can be closed when we review the BOP’s guidance to
institutions and receive documentation showing that appropriate
institution staff have received the on-line training.
11. Resolved. We recommended the BOP establish a process for reviewing
the health care performance measures reported by institutions that
includes actions that will be taken when institutions are not meeting the
target performance levels. The BOP agreed and stated that it issued a
memorandum on February 12, 2008, to all Bureau Wardens, notifying
them of changes to the national performance measures and reiterating
the policy requirement to collect and report these measures. An on-line
training session for institution Health Services staff was conducted
February 13, 2008, to discuss the changes and the reporting
requirements. The BOP stated that the Health Services Division’s Office
of Quality Management will be collecting and reviewing this data
semiannually and reporting to the Regional Medical Directors when
institutions are not meeting the expected target levels. The BOP stated
that Regional Medical Directors will ensure that national performance
measures are addressed at each institution under their oversight. The
BOP further stated that Regional Medical Directors will assess target
level failures, provide recommendations for improvement, and follow-up
during Clinical Director peer reviews. The recommendation can be
closed when we review the February 12, 2008, memorandum and
documentation for the on-line training conducted on February 13, 2008,
showing the subjects covered.

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