	Background

BOP is responsible for approximately 219,600 inmates in federal custody. Mental Health Services Costs Have Increased in BOP- Operated Institutions since Fiscal Year 2008 and Are Expected to Continue to Increase

During the 5-year period starting in fiscal year 2008 and ending in fiscal  year 2012, costs for inmate mental health services in BOP-operated  institutions rose in absolute dollar amount, as well as on an annual per  capita—or per inmate—basis. As shown in table 3,  when aggregating these costs, we found that total costs increased  annually from $123 million in fiscal year 2008 to nearly $146 million in  fiscal year 2012. These increases were due in part to a concurrent  population increase of more than 11,000 inmates during the period. BOP Assesses Compliance with Its Policies for Inmate Mental Health Services, but Reviews Are Not Always Timely; BOP Has Not Evaluated the Effectiveness of Most Treatment Programs or Updated Most Policies

BOP conducts various internal reviews to assess BOP-operated  institutions’ compliance with its policies related to mental health services,  and BOP policy also requires institutions to obtain external accreditations. Additionally, BOP has not evaluated the effectiveness of most of its  treatment programs and has not developed a plan to do so. Finally,  BOP’s program statements related to mental health services, which  formally document BOP’s policies and procedures, contain outdated  information. BOP Conducts Internal Reviews That Assess Compliance with Policies for Mental Health Services, but Most Reviews Do Not Occur on Time

BOP’s psychology and health services program reviews identify the  extent to which institutions are complying with BOP policies. VII for additional information  on the elements of a MTC.) As part a statutory requirement, BOP is  to provide an annual report containing statistics demonstrating the relative  reductions in recidivism associated with major inmate programs (including  residential drug treatment, vocational training, and prison industries  programs).BOP officials told us they have begun to develop an approach to  complete the first report, which they plan to submit to Congress in 2016. With a plan, BOP  could have greater assurance that the activities necessary to conduct the  evaluations of the psychology treatment programs, as well as any needed  program changes that may be identified during those evaluations, would  be completed in a timely manner. The performance-based,operation of BOP’s privately managed facilities give flexibility to the  contractors to decide how to provide mental health services. BOP Does Not Track Contractors’ Cost of Providing Inmate Mental Health Services in Contract Facilities

BOP tracks the overall daily cost for housing the 13 percent of federal  inmates—who are generally designated as mental health care level 1—in  its 15 contract facilities, but BOP does not track the specific costs of  providing mental health services to these inmates. This is because the  BOP contracts that govern the operation of these privately managed  facilities are performance-based, fixed-price contracts that only require  the contractors to provide BOP with their costs on a per inmate per day  basis. However, when  reviews are postponed, the delays can be lengthy—sometimes over a  year—even for those institutions with the lowest ratings. By updating and  implementing mental health care-related program statements, BOP would  better ensure that its policies reflect currently accepted treatment  practices and standards. Recommendations for Executive Action

To improve BOP’s ability to oversee BOP-operated institutions’  compliance with inmate mental health policies and monitor the  effectiveness of treatment programs for mentally ill inmates, we  recommend that the Director of BOP take the following two actions: when program reviews are delayed, ensure institutions with the lowest  ratings receive the highest priority for the completion of reviews; and develop a plan to carry out future evaluations of BOP’s psychology  treatment programs, within available resources; the plan should  include the identification of necessary resources and target time  frames. However, in an e-mail received on June 27, 2013, a BOP audit liaison  official stated that BOP concurred with the first and third  recommendations and partially concurred with the second  recommendation, which called for the Director of BOP to assess which  psychology treatment programs could be evaluated within the agency’s  existing resources and develop a plan to conduct future evaluations. 2. 3. To address the question on the BOP’s costs over the past 5 fiscal years  and projected costs to provide inmate mental health services in BOP- operated institutions, we interviewed officials from BOP’s Administrative  Division, Psychology Services Branch, and Health Services Division to  understand what constitutes mental health services, what costs are  relevant to providing these services, what factors drive changes in cost,  and BOP’s current practices for developing budgets and expenditure  plans in these areas. provided to inmates and oversight of staff working at the institutional level. To address the question about the extent to which BOP tracks the costs  of providing mental health services to BOP inmates in contract facilities,  and the extent to which BOP assesses whether these facilities meet  contract requirements and established accreditation standards for inmate  mental health services, we reviewed the contracts for all of the 15  contract facilities that housed BOP inmates during the course of our  review to see what cost information they included. The Habilitation Program was  discontinued in fiscal year 2012. We reviewed the most recent psychology services and health services  internal program review reports for the 47 BOP institutions in our sample.
Why GAO Did This Study

BOP is responsible for the care and custody--including mental health care--of more than 219,600 federal inmates. BOP identifies and treats inmates' mental health disorders, and has procedures in place to assess the provision of mental health services in its 119 facilities, and 15 private prisons operating under contract. GAO was requested to provide information on BOP's costs and oversight of inmate mental health services. This report addresses: (1) BOP's costs to provide these services; (2) the extent to which BOP assesses whether its institutions comply with BOP policies for providing services; and (3) the extent to which BOP tracks the costs of providing mental health services to inmates in contract facilities, and assesses compliance with contract requirements.
GAO analyzed obligated funds for fiscal years 2008 through 2012 for the two BOP divisions responsible for mental health services at BOP institutions, examined the most recent review reports for a random sample of 47 BOP institutions and all 15 contract facilities, examined BOP's policies, and interviewed BOP officials.

What GAO Found

During a 5-year period--fiscal years 2008 through 2012--costs for inmate mental health services in institutions run by the Bureau of Prisons (BOP) rose in absolute dollar amount, as well as on an annual per capita basis. Specifically, mental health services costs rose from $123 million in fiscal year 2008 to $146 million in fiscal year 2012, with increases generally due to three factors--inmate population increases, general inflationary increases, and increased participation rates in psychology treatment programs such as drug abuse treatment programs. Additionally, the per capita cost rose from $741 in fiscal year 2008 to $821 in fiscal year 2012. It is projected that these costs will continue to increase with an estimated per capita cost of $876 in fiscal year 2015, due, in part, to increased program funding and inflation.
BOP conducts various internal reviews that assess institutions' compliance with its policies related to mental health services, and it also requires institutions to obtain external accreditations. BOP's internal program reviews are on-site audits of a specific program, including two that are relevant to mental health services--psychology and health services. Most institutions in GAO's sample received good or superior ratings on their psychology and health services program reviews, but these reviews did not always occur within BOP-established time frames, generally due to lack of staff availability. When reviews were postponed, delays could be lengthy, sometimes exceeding a year, even for those institutions with the lowest ratings in previous reviews. Moreover, BOP has not evaluated whether most of its psychology treatment programs are meeting their established goals and has not developed a plan to do so. BOP is developing an approach for reporting on the relative reduction in recidivism associated with major inmate programs, which may include some psychology treatment programs. Using this opportunity to develop a plan for evaluating its psychology treatment programs would help ensure that the necessary evaluation activities, as well as any needed program changes, are completed in a timely manner. Further, BOP's program statements--its formal policies--related to mental health services contain outdated information. Policy changes are instead communicated to staff through memos. By periodically updating its program statements, BOP would be better assured that staff have a consistent understanding of its policies, and that these policies reflect current mental health care practices.
BOP collects information on the daily cost to house the 13 percent of federal inmates in contract facilities, but it does not track the specific contractor costs of providing mental health services. The performance-based, fixed-price contracts that govern the operation of BOP's contract facilities give flexibility to the contractors to decide how to provide mental health services and do not require that they report their costs for doing so to BOP. BOP uses several methods to assess the contractors' compliance with contract requirements and standards of care. BOP conducts on-site reviews to assess the services provided to inmates in contract facilities, including those for mental health. BOP uses results from these reviews, as well as reports from external accrediting organizations, the presence of on-site monitors, and internal reviews conducted by the contract facility, to assess contractor compliance and to ensure that the contractor is consistently assessing the quality of its operations.

What GAO Recommends

GAO recommends that BOP (1) take steps to prioritize the completion of postponed program reviews, (2) develop a plan to evaluate treatment programs, and (3) develop and implement updated program statements. BOP concurred with the first and third recommendations and partially concurred with the second. GAO considered additional information provided by BOP about its plan to conduct evaluations and modified this recommendation accordingly.