The fiscal year 2015 ADP  in these facilities totaled approximately 28,000 detainees. DHS Has Established Processes for Providing Detainee Medical Care, but Does Not Have Complete Data on Costs for Care

		All Detention Facilities Provide On-site Medical Care

DHS has established processes for the provision of routine medical care  on-site at both IHSC and non-IHSC staffed facilities. For example, at the 19 over-72-hour facilities where IHSC provided  direct medical care to detainees in fiscal year 2015, ICE maintained  medical expenditure data in its accounting system of record, the Federal  Financial Management System. However, ICE’s system for managing the  provision of off-site medical care does not provide ICE with the  information needed to identify and assess trends across the types of off- site care requested or approved over time or across facility types, and  ICE could better link data on approvals and amounts paid to improve ICE  oversight of the costs of providing off-site medical care to detainees. However, the number of claims paid for fiscal years 2012  through 2014 did not correspond to the number of IHSC MedPAR  authorizations, or approvals for requested services, for the same time  period. For  example, an emergency room visit may require one MedPAR approval,  but claims may be paid to multiple providers associated with the visit. In addition,  establishing stronger internal controls to ensure that payments for off-site  care are supported by the appropriate authorizations could help ICE  monitor medical care costs and better validate payments. ICE Uses Various Oversight Mechanisms and Collects Medical Care Compliance Data at Individual Facilities, but Conducts Limited Analyses of Data across Facilities

		ICE Uses Various Mechanisms to Oversee Facilities’ Compliance with Medical Care Standards

ICE has various mechanisms to oversee medical care at facilities, and it  uses a combination of these mechanisms to monitor conditions within a  facility, including the quality of medical care. In these ways, facilities can  resolve issues and improve the conditions of confinement for detainees in  a timely manner. Similarly,  CMD officials stated that their priority has been to address issues at  individual facilities rather than to conduct analyses of data across  facilities. Expanding analysis of oversight data across facilities would strengthen  ICE’s ability to manage and oversee the provision of medical care across  facility types. As shown in figure 6, various DHS entities obtain complaints, and IHSC  ultimately receives and is responsible for addressing medical complaints  obtained by those entities. Similarly,  there are multiple avenues for detainees or others to file medical  complaints, such as toll-free telephone hotlines or formal written  complaints, and all medical complaints eventually are received by IHSC  for resolution. Recommendations for Executive Action

To enhance Department of Homeland Security’s (DHS) U.S. Immigration  and Customs Enforcement’s (ICE) ability to make more effective business  decisions across immigration detention facilities with respect to the  provision of medical care, we recommend that the Secretary of Homeland  Security direct ICE to take the following actions: develop and implement a mechanism to identify and assess trends in  off-site medical care procedures across types of procedures and develop and implement a mechanism to ensure that payments for off- site care are supported by the appropriate authorizations; and track inspection results and conduct analyses of oversight data over  time, by standards, and by facility type. Additionally, we recommend that the Secretary of Homeland Security  ensure that IHSC’s planned new tasking system includes all medical- care-related complaints received by DHS entities, and that this system  facilitates the tracking and analysis of complaints over time and across  facilities. Appendix I: Objectives, Scope, and Methodology

This report addresses to what extent does the Department of Homeland  Security (DHS):  1.  have processes for administering medical care to immigration  detainees and maintaining information on costs associated with care,  2.  assess and monitor compliance with medical care standards at  3.  oversee processes to obtain and address complaints about medical  care in immigration detention facilities? To determine the extent to which DHS oversees immigration detention  medical care complaint mechanisms, we analyzed and compared Office  for Civil Rights and Civil Liberties (CRCL), Detention and Reporting  Information Line (DRIL), IHSC, Joint Intake Center (JIC), and Office of the  Inspector General (OIG) processes for obtaining and addressing  complaints; analyzed fiscal year 2014 complaint data maintained by these  DHS entities’ data systems; and reviewed ICE detention and family  residential standards that govern facility grievance systems. Appendix IV: Description of U.S. Immigration and Customs Enforcement (ICE) Medical Care Oversight Mechanisms

Based on our review of ICE policy, ICE uses the following seven  oversight mechanisms to assess facility compliance with medical care  detention standards and to inspect the quality of medical care at facilities:
Custody Management Division (CMD) Inspections
Operational Review Self-Assessments (ORSA)
Field Medical Coordinator (FMC) Site Visits  ICE Health Service Corps (IHSC) Quality Improvement Audits
Office of Detention Oversight (ODO) Inspections
Detention Service Managers (DSM)
During fiscal year 2015, more than 99 percent of ICE’s average daily  population (ADP) was covered by two or more of these oversight  mechanisms. Inspections are conducted annually or biennially at facilities that are  authorized to house detainees for more than 72 hours, and that have an  ADP of 10 or more detainees.
Why GAO Did This Study

DHS is responsible for providing safe, secure, and humane confinement for detained aliens who may be subject to removal or have been ordered removed from the United States. GAO was asked to examine the provision and oversight of medical care in immigration detention facilities. This report examines the extent to which DHS (1) has processes for administering detainee medical care and maintaining cost information for care, (2) monitors and assesses compliance with medical care standards, and (3) oversees processes to obtain and address complaints about detainee medical care.
GAO reviewed ICE data and information on costs, detention population, standards, and oversight for 165 facilities that held detainees for more than 72 hours in fiscal year 2015. GAO also reviewed complaint processes, interviewed DHS and ICE officials, and visited 12 facilities selected based on detainee population and facility type, among other factors. The visit results are not generalizable, but provided insight to the provision of medical care.

What GAO Found

The Department of Homeland Security's (DHS) U.S. Immigration and Customs Enforcement (ICE) oversees basic on-site medical care at all facilities, as required by ICE detention standards, but does not maintain complete information about medical care costs. The ICE Health Service Corps (IHSC) provided direct care to detainees at 19 over-72-hour facilities and oversaw care at the remaining 146 non-IHSC-staffed facilities in fiscal year 2015. At all facilities, IHSC uses an electronic system, the Medical Payment Authorization (MedPAR) system, to approve or deny off-site care requests for detainees; such requests could include dental visits or surgical needs. IHSC uses a system different from MedPAR to track costs or amounts paid for off-site care. The use of separate systems limits ICE's ability to link approvals and payments. For example, the number of claims paid for fiscal years 2012 through 2014 did not correspond to the number of IHSC MedPAR approvals for requested services for the same time period. While there are valid reasons for these differences, such as that approvals and claims could be made in different fiscal years, establishing a mechanism to more fully ensure that payments for off-site care are supported by the appropriate authorizations could help ICE monitor medical care costs and better validate payments.
ICE conducts medical care compliance inspections at individual facilities, but conducts limited analyses of inspection data across facilities and over time. ICE uses seven oversight mechanisms to monitor facilities' compliance with medical care detention standards, such as facility inspections and on-site detention monitors. The combined use of these oversight mechanisms resulted in more than 99 percent of ICE's average daily population (ADP) of approximately 28,000 detainees being covered by two or more mechanisms in fiscal year 2015. ICE's priority has been to focus on local, facility-specific issues rather than perform overarching analyses. For example, ICE does not utilize the data gathered through these mechanisms in a way that examines overall trends in medical care deficiencies. Conducting analysis of oversight data over time, by detention standards, and across facilities, consistent with internal control standards, could strengthen ICE's ability to manage and oversee the provision of medical care across facility types.
DHS has various processes to obtain and address the hundreds of medical care complaints it receives annually. Specifically, detainees can submit complaints regarding medical care directly to facilities or to one of various DHS entities, including the Office of Inspector General and Office for Civil Rights and Civil Liberties. These entities generally determine whether to take their own action on the complaints or forward them to ICE for resolution. These entities maintain complaint data in various ways, and IHSC, which is ultimately responsible for addressing medical complaints received, is developing and piloting a new system for managing tasks, including addressing complaints. However, internal control standards call for evaluation of performance over time, and it is unclear whether IHSC's new system will capture all medical complaints received by DHS or facilitate analyses of complaints over time and across facilities. Ensuring that a new tasking system would capture all complaints and facilitate analysis could improve DHS's decision-making for detainee medical care.

What GAO Recommends

GAO recommends that DHS, among other things, ensure payments for medical care are supported by authorizations, conduct trend analyses of oversight data, and track all medical complaints received by DHS entities. DHS concurred with the recommendations and identified planned actions to address the recommendations.