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Highlights

What GAO Found

From fiscal years 2009 through 2016, the Bureau of Prisons (BOP) obligated more than $9 billion for the provision of inmate health care and several factors affected these costs. Obligations for health care rose from $978 million in fiscal year 2009 to $1.34 billion in fiscal year 2016, an increase of about 37 percent. On a per capita basis, and adjusting for inflation, health care obligations rose from $6,334 in fiscal year 2009 to $8,602 in fiscal year 2016, an increase of about 36 percent. BOP cited an aging inmate population, rising pharmaceutical prices, and increasing costs of outside medical services as factors that accounted for its overall costs.

Bureau of Prisons (BOP) Institution Obligations for Inmate Health Care, Including Psychological Care, and Inflation Adjusted Per Capita Obligations from Fiscal Years 2009 through 2016

Fiscal year

 

2009

2010

2011

2012

2013

2014

2015

2016

Total health care obligations (millions)

$978

$1,035

$1,081

$1,122

$1,200

$1,243

$1,299

$1,344

Per capita obligations (2016 dollars)

$6,334

$6,495

$6,485

$6,627

$6,998

$7,350

$7,958

$8,602

Source: GAO analysis of BOP data. GAO-17-379

BOP lacks or does not analyze certain health care data necessary to understand and control its costs. For example, while BOP's data can show how much BOP is spending overall on health care provided inside and outside an institution, BOP lacks utilization data, which is data that shows how much it is spending on individual inmate's health care or how much it is expending on a particular health care service. BOP has identified potential solutions for gathering utilization data, but has not conducted a cost-effectiveness analysis of these solutions to identify the most effective solution. BOP also does not analyze health care spending data, i.e., what its institutions are buying, from whom, and how much they spend. BOP has pursued some opportunities to control its health care spending through interagency collaboration and national contracts, but it has not conducted a spend analysis to better understand trends. Doing so would provide BOP with better information to acquire goods and services more strategically.

BOP has initiatives aimed to control health care costs but could better assess effectiveness and apply a sound planning approach. Since 2009, BOP has implemented or planned a number of initiatives related to health care cost control, but has not evaluated their cost-effectiveness. Further, BOP has engaged in a strategic planning process to help control costs, but has not incorporated certain elements of a sound planning approach, such as developing a means to measure progress toward its objectives and identifying the resources and investments needed for its initiatives. By incorporating these elements, BOP could enhance its planning and implementation efforts before expending resources, better positioning itself for success as it aims to control health care costs.

Why GAO Did This Study

As of June 2017, BOP was responsible for the custody and care—including health care—of about 154,000 inmates housed in BOP institutions. Health care includes medical, dental, and psychological treatment. BOP provides most care inside its institutions, but transports inmates outside when circumstances warrant. GAO was asked to review health care costs at BOP institutions.

This report addresses: (1) BOP's costs to provide health care services and factors that affect costs; (2) the extent to which BOP has data to help control health care costs; and (3) the extent to which BOP has planned and implemented cost control efforts.

GAO analyzed BOP health care obligations data for fiscal years 2009 through 2016, gathered information on BOP's health care cost control initiatives through a data collection instrument, and reviewed BOP's health care related strategic plans. GAO also interviewed BOP officials and visited 10 BOP institutions, selected in part, for total and per capita medical services costs.

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Recommendations

GAO is making five recommendations, including that BOP conduct a cost-effectiveness analysis to identify the most effective method to collect health care utilization data; conduct a spend analysis of health care spending data; evaluate cost control initiatives; and enhance its planning efforts by incorporating elements of a sound planning approach. BOP concurred with the recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Bureau of Prisons To better understand the available opportunities for collecting inmate health care utilization data, BOP should conduct a cost-effectiveness analysis of potential solutions, and take steps toward implementation of the most effective solution.
Closed - Implemented
BOP agreed with GAO's June 2017 recommendation and took steps to implement it. In 2018, BOP contracted with a management consulting firm to undertake an independent expert assessment, which would, in part, provide a cost-effectiveness analysis of potential solutions for collecting inmate health care utilization data. This assessment produced five reports. The first two were completed in October 2019 and assessed BOP's organizational alignment with healthcare operations, and provided effective practices in strategic planning and change management for the Health Services Division within BOP. The last three reports were completed in September 2020, and focused on providing data analytics solutions, including recommendations for methods to collect health care utilization data. In May 2021, BOP took steps, based on recommendations in the reports, to work towards improving data analytics capabilities. For example, BOP stated that it had committed resources to evaluate a potential upgrade to the existing data analytics platform, which will streamline the processing of raw data, and provide operational data and additional tools for analytics to BOP staff. Additionally, BOP entered into a contract in May 2021 with an organization to conduct an examination of critical functions that are the foundation of an effective medical data management system. This system will enable the collection, management, and governance of medical and financial data. By taking steps to implement a solution for collecting inmate health care utilization data, BOP will be better positioned to understand and control health care costs. As a result, we have closed this recommendation as implemented.
Bureau of Prisons To better understand the available opportunities for controlling health care costs, BOP should implement its guidance to conduct "spend analyses" of BOP's health care spending, using data sources already available
Closed - Implemented
BOP agreed with GAO's June 2017 recommendation and took steps to implement it that even exceeded the scope of the recommendation itself. For example, in 2018, BOP contracted with a management consulting firm. The goal was to undertake an independent assessment to identify opportunities to strengthen data analytics of sources already available and to improve organization alignment for improved control of health care costs. This assessment produced five reports. The first two were completed in October 2019 and assessed BOP's organizational alignment with healthcare operations, and provided effective practices in strategic planning and change management for the Health Services Division within BOP. The last three reports were completed in September 2020, and focused on providing data analytics solutions. BOP provided an update in April 2021 stating that it had implemented an organizational change recommended in one of the reports. Specifically, it placed BOP's National Health Service Administrator in a direct line of authority over BOP's Regional Health Service Administrators, which provided BOP's headquarters access to regional health care spending data, among other benefits. BOP also stated that the Health Services Division staff now has full access to financial data regarding health care spending and are able to review Federal Procurement Data Systems-Next Generation award data, which BOP will use to analyze data on a monthly basis to track BOP's health care spending. BOP also identified strategic sourcing opportunities for national contracts. For example, BOP entered into a national contract in January 2021 for lab services such as blood work analysis, drug testing, and COVID-19 testing, among others. Additionally, as of May 2021, BOP was deliberating on two additional national contracts-one for medical equipment and one for a Pharmacy Benefit Management program for Residential Reentry Centers. Finally, BOP has conducted multiple spend analyses, including an analysis of savings realized as a result of BOP adopting use of a nationwide Medical Surgical Prime Vendor contract, which is a collection of contracts for an array of medical, surgical, dental, and lab supplies. BOP has also conducted multiple analyses on pharmaceutical expenditures, among others. By implementing an organizational change, conducting spend analyses, and pursuing national contracts, BOP is better positioned to understand available opportunities for controlling health care costs. As a result, we have closed this recommendation as implemented.
Bureau of Prisons To determine the actual or likely effectiveness of its ongoing or planned health care cost control initiatives, BOP should evaluate the extent to which its initiatives achieve their cost control aim.
Closed - Implemented
BOP agreed with GAO's June 2017 recommendation and took steps to implement it. BOP established the Health Services Division Initiatives Program Management Advisory Group (IPMAG) in January 2021 to evaluate the effectiveness of its ongoing and planned health care cost control initiatives. The IPMAG meets every two weeks to review and track the Health Services Division's current and planned initiatives. Each initiative is assigned a point of contact and is routinely assessed during IPMAG meetings regarding overall status, current action steps, target dates for completion, and continued feasibility and forecasted effectiveness. According to BOP, IPMAG also ensures consistent practices across BOP and oversees the progress and ultimate completion of health care initiatives to ensure BOP Central Office programs evolve in a direction that optimizes patient outcomes, with a cost-effective, consistent approach to healthcare delivery. Additionally, BOP stated that the Health Services Division staff now has full access to financial data regarding health care spending, which allows BOP to evaluate cost control initiatives. Finally, BOP stated that it has already evaluated two initiatives, the pharmaceutical program and the national Medical Surgical Prime Vendor contract, which is a collection of contracts for an array of medical, surgical, dental, and lab supplies. By establishing the IPMAG to regularly track and monitor BOP's health care cost initiatives, BOP is better positioned to evaluate the extent to which its initiatives achieve their cost control aim. As a result, we have closed this recommendation as implemented.
Bureau of Prisons To enhance its strategic planning for and implementation of health care cost control efforts, BOP should incorporate elements of a sound planning approach and (1) establish a means of measuring progress toward and effectiveness of its activities for its current strategic objectives and goals related to controlling health care costs; and (2) identify the resources and investments necessary for implementation of its planned health care cost control initiatives.
Closed - Implemented
We found that the Federal Bureau of Prisons' (BOP) overall planning practices had not incorporated certain elements of sound planning that we had previously identified, such as the identification of objectives with a means to measure progress and effectiveness of those objectives. As a result, we recommended that BOP enhance its strategic planning by incorporating elements of a sound planning approach and (1) establish a means of measuring progress toward and effectiveness of its activities for its current strategic objectives and goals related to controlling health care costs; and (2) identify the resources and investments necessary for implementation of its planned health care cost control initiatives. In February 2020 BOP established the Strategic Plan Advisory Group, which began meeting regularly and was tasked with developing a strategic plan. By June 2021, the Advisory Group finalized the Health Services Division Strategic Plan 2020-2024. The strategic plan includes the use of action steps, which reflect efforts that are needed to reach specific strategic objectives and establish a means to measure progress. The action steps also identify in broad terms the resources and investments needed to achieve strategic objectives. The development of the Health Services Division Strategic Plan is consistent with our recommendation.
Bureau of Prisons To improve the reliability and utility of its Federal Medical Center mission analyses, BOP should document the analyses and findings that underlie its recommendations.
Closed - Implemented
We found that the Federal Bureau of Prisons (BOP) employed a process to assess the effectiveness of its care in Federal Medical Centers, but did not document these analyses and therefore lacked a record to support decision-making for its resource allocations. As a result, we recommended that BOP document the analyses and findings that underlie its recommendations of its Federal Medical Centers. BOP decided to end the Federal Medical Center mission analyses process and instead, in September 2018 established a Medical Referral Center Executive Advisory Board, comprised of Health Services Division leadership and wardens from all seven Federal Medical Centers. In January 2020, BOP reported that this Board had implemented a pipeline patient dashboard, which permits wardens of Federal Medical Centers to monitor incoming patients in advance of arrival and to maximize the best patient care and housing until treatment is complete. In addition, the Board developed and implemented a Memory Disorder Unit at one of the Federal Medical Centers, which resulted in BOP making more efficient use of its inpatient beds. In August 2021 BOP reported that Board resumed meeting on a regular basis in calendar year 2021 after a brief pause due to COVID-19. As part of its regular meetings, the Board discusses metrics for cost analysis initiatives and expenditures for outside hospital trips, medical/surgical supplies, contractor costs, and specialized patient treatments. The establishment of the Medical Referral Center Executive Advisory Board and the subsequent actions of the Board are consistent with the intent of our recommendation.

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