	Background

As of June 2017, BOP was responsible for approximately 188,000  inmates in federal custody. About 81 percent, or approximately 154,000  inmates, are housed in BOP-operated institutions. BOP provides most medical and dental care inside its institutions (inside  care), usually with BOP-employed medical staff. BOP Obligated More Than $9 Billion for Inmate Health Care From Fiscal Years 2009 through 2016 and Several Factors Affected Costs

		BOP’s Annual Health Care Obligations Have Increased Overall and on a Per Capita Basis

During the 8-year period starting in fiscal year 2009 and ending in fiscal  year 2016, BOP obligated more than $9 billion for the provision of inmate  health care. After adjusting for inflation, per capita  health care obligations increased from $6,334 per inmate in fiscal year  2009 to $8,602 per inmate in fiscal year 2016, or an increase of about 36  percent during this time period. Officials frequently cited the following as major factors:  inmates entering with relatively poorer health, aging inmates,  rising pharmaceutical prices, and outside medical services. BOP Lacks or Does Not Analyze Certain Health Care Data Necessary to Understand and Control its Costs

		BOP Lacks Health Care Utilization Data

BOP lacks data on the health care services it provides to inmates, which  is otherwise known as health care utilization data. Specifically, BOP is planning to pilot a regional comprehensive  medical services contract. By conducting a cost-effectiveness analysis of the  potential ways to obtain health care utilization data, BOP will be better  positioned to determine the most cost-effective way to collect such data  and to start doing so in a timely manner. BOP Does Not Analyze Available Health Care Spending Data

BOP has not consistently collected and analyzed its institutions’ health  care spending data to identify additional cost control opportunities, such  as through strategic sourcing. BOP Has Initiatives Aimed to Control Health Care Costs but Has Not Assessed Their Effectiveness, Applied a Sound Planning Approach, or Documented its Analyses of Federal Medical Centers’ Missions

		BOP Has Initiatives Intended to Control Health Care Costs but Has Not Evaluated Their Effectiveness

BOP has taken bureau-wide actions to help control health care costs  through several initiatives, but has generally not evaluated the  effectiveness of these initiatives. Conducting a comprehensive  spend analysis could help BOP identify additional strategic sourcing  opportunities to acquire medical goods and services more efficiently. By  incorporating these sound planning 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. 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. To enhance its strategic planning for and implementation of health  care cost control efforts, BOP should incorporate elements of a sound  planning approach and 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  identify the resources and investments necessary for  implementation of its planned health care cost control initiatives. However, in an e-mail received on June 20, 2017, a DOJ official stated  that BOP concurred with all five recommendations. Appendix I: Objectives, Scope, and Methodology

Our objectives for this report were to examine: (1) how much the Bureau  of Prisons (BOP) has obligated for inmate health care from fiscal years  2009 through 2016 and the factors that affect BOP’s costs, (2) the extent  to which BOP has data available to understand and help control its costs,  and (3) the initiatives BOP has identified and implemented to help control  health care costs and the extent to which BOP has effectively planned its  health care cost control efforts.
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.

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.
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.

What GAO Recommends

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.