Office of the Inspector General

U.S. Department of Justice

Review of the Federal Bureau of 

Prisons’ Medical Staffing Challenges 


Evaluation and Inspections Division 16-02

March 2016

EXECUTIVE SUMMARY

Introduction
The Federal Bureau of Prisons (BOP) is responsible for incarcerating federal
inmates and is required to provide them with medically necessary healthcare.
However, recruitment of medical professionals is one of the BOP’s greatest
challenges and staffing shortages limit inmate access to medical care, result in an
increased need to send inmates outside the institution for medical care, and
contribute to increases in medical costs. Additionally, medical staff shortages can
impact prison safety and security. For example, according to an After-Action
Report prepared after a riot at a BOP contract prison, the BOP noted that while low
medical staffing levels alone were not the direct cause of the disturbance, they
affected security and health services functions.1
As of September 2014, the BOP had 3,871 positions in its institutions’ health
services units to provide medical care to 171,868 inmates. Of those 3,871
positions, only 3,215 positions (83 percent) were filled.2 Although BOP policy
states that the vacancy rate shall not exceed 10 percent during any 18-month
period, we found that only 24 of 97 BOP institutions had a medical staffing rate of
90 percent or higher as of September 2014.3 Further, 12 BOP institutions were
medically staffed at only 71 percent or below, which the BOP’s former Assistant
Director for Health Services and Medical Director described as crisis level.
Both civilian and uniformed staff hold these 3,215 filled healthcare positions.
This includes 2,382 civil service employees and 833 commissioned officers of the
U.S. Public Health Service (PHS), an agency of the U.S. Department of Health and
Human Services, which provides public health services to underserved and
vulnerable populations. The Department of Justice’s Office of the Inspector General
(OIG) conducted this review to assess challenges the BOP faces in hiring medical
professionals and its use of PHS officers as one method of addressing those
challenges.
Results in Brief
The OIG found that recruitment and retention of medical professionals is a
serious challenge for the BOP, in large part because the BOP competes with private
1

Department of Justice (DOJ) Office of the Inspector General (OIG), Audit of the Federal
Bureau of Prisons Contract No. DJB1PC007 Awarded to Reeves County, Texas, to Operate the Reeves
County Detention Center I/II, Pecos, Texas, Audit Report 15-15 (April 2015),
https://oig.justice.gov/reports/2015/a1515.pdf (accessed February 8, 2016).
2

This reflects the population in BOP-managed institutions only. Inmates in contract
institutions and residential reentry centers are excluded.
3

There were 121 BOP-managed institutions as of September 2014, but the BOP considers
correctional complexes (multiple institutions co-located) to be a single institution when reporting
staffing levels. This reduces the number of institutions to 97.

i

employers that offer higher pay and benefits. We further found that the BOP has
not proactively identified and addressed its medical recruiting challenges in a
systemic way. Rather, it has attempted in an uncoordinated fashion to react to
local factors influencing medical recruiting at individual institutions. Moreover, we
found that the BOP does not take full advantage of staffing flexibilities the PHS
offers that could assist in addressing some of its most difficult medical staffing
challenges.
The BOP’s Compensation and Incentives Offered to Civil Service Medical Staff Are
Not Sufficient to Alleviate Staffing Shortages
Multiple factors, including the location of institutions, pay, and the
correctional setting, negatively impact the BOP’s ability to recruit and retain medical
professionals. Civil service employee pay is governed by the General Schedule
(GS) pay scale and U.S. Office of Personnel Management policies regarding how
positions are classified. We found a significant gap between GS salaries and local
average salaries for comparable healthcare positions; these gaps persisted across
multiple medical professions and in both urban and rural communities. For
example, BOP staff told us that it was particularly difficult to recruit pharmacists
and we found that the average pharmacist salary in communities where BOP
institutions are located was approximately double the mid-range salary the BOP can
offer.4 In an attempt to narrow these gaps, the BOP has increasingly relied on
monetary and nonmonetary incentives and it plans to implement an alternative
federal pay system for psychiatrists in fiscal year (FY) 2016. However, we found
that these are not always sufficient to reduce the medical staffing vacancies the
BOP faces. Faced with continuous understaffing, the BOP uses temporary duty
(TDY) assignments and contracted medical providers to ensure that it can continue
to provide inmates with necessary medical care. However, both of these options
come with additional costs. Additionally, according to BOP officials, the limits of the
GS pay scale mean that PHS compensation and benefits are more competitive for
some professions.
The BOP Does Not Identify or Address Recruiting Challenges in an Agency-wide and
Strategic Manner
The BOP’s current method of addressing medical recruiting challenges
focuses primarily on individual institutions’ immediate needs. As a result, the BOP
does not strategically assess which vacancies have the greatest overall impact on
its ability to provide medical care to inmates. The BOP collects and maintains data
that, if analyzed, could help it better assess and prioritize its needs and develop a
strategy to meet those needs agency-wide. Such a process would include
evaluating vacancies, the use of incentives, the use of TDY assignments, and the
cost of outside medical care across all institutions. This would help the BOP identify
the vacancies that are most costly to leave unfilled and to prioritize staffing in those
locations.
4

We compared average salaries reported by the Bureau of Labor Statistics with salaries in the
middle of the range on the General Schedule salary table. For more information, see Appendix 1.

ii

The BOP Does Not Use the Authority It Has to Assign PHS Officers to Positions
Based on Greatest Need
The conditions of PHS officers’ employment make them more mobile than
civil service employees, and the PHS has created promotion incentives that benefit
PHS officers who change duty stations; but the BOP does not take advantage of
these flexibilities to assign PHS officers to positions based on greatest need. BOP
officials expressed concerns to us that one method of using those flexibilities,
involuntary transfers, could lead to unintended effects, such as PHS officers leaving
the BOP for work in other agencies. However, involuntary transfers are not the
BOP’s only option for determining where PHS officers should work, as the BOP may
alternatively require PHS officers to spend their first few years with the BOP filling
high-priority positions, which could appeal to PHS officers seeking promotion. We
believe the BOP should better utilize PHS officer flexibility to address medical
vacancies of greatest impact.
Recommendations
As the BOP struggles to fill its medical staffing needs, and as medical costs
continue to rise, the BOP must collect better information on its priority health
services vacancies and find solutions to meet the medical needs of its inmates. In
this report, we make two recommendations to help the BOP improve its ability to
assess the impact of medical vacancies on BOP operations and to develop a
strategy to better utilize PHS officer flexibility to address medical vacancies of
greatest impact.

iii

TABLE OF CONTENTS 

INTRODUCTION ............................................................................................ 1 

The BOP’s Responsibility to Provide Medical Care to All Inmates ................. 2 

Scope and Methodology of the OIG Review.............................................. 6 

RESULTS OF THE REVIEW .............................................................................. 7 

The BOP’s Compensation and Incentives Offered to Civil Service

Medical Staff Are Not Sufficient to Alleviate Staffing Shortages ................... 7
 
The BOP Does Not Identify or Address Recruiting Challenges in 

an Agency-wide and Strategic Manner .................................................. 16
 
The BOP Does Not Use Its Authority to Assign PHS Officers to 

Positions Based on Greatest Need ........................................................ 20
 
CONCLUSION AND RECOMMENDATIONS ........................................................ 26 

Conclusion ........................................................................................ 26 

Recommendations ............................................................................. 27 

APPENDIX 1: EXPANDED METHODOLOGY ...................................................... 28 

Data Analysis .................................................................................... 28 

Interviews ........................................................................................ 29 

Site Visits ......................................................................................... 29 

Additional Objectives.......................................................................... 29 

APPENDIX 2: THE BOP’S RESPONSE TO THE DRAFT REPORT............................ 31 

APPENDIX 3: OIG ANALYSIS OF THE BOP’S RESPONSE ................................... 33 


INTRODUCTION
As of September 2014, the Federal Bureau of Prisons (BOP) employed over
2,300 civil service employees and over 800 U.S. Public Health Service (PHS)
officers to provide medical care to an inmate population of 171,868 in
121 institutions.5 However, these staffing levels fell short of the BOP’s staffing
goals: from fiscal year (FY) 2010 to FY 2014, the BOP’s total medical staff was
approximately 17 percent less than what the BOP projected was necessary to
provide what it considers to be “ideal” care.
Staffing shortages are a reflection of the BOP’s challenges to recruit and
retain medical staff. Although BOP policy states that “the vacancy rate of staff
positions that work directly with inmates shall not exceed 10 percent during any
18 month period,” the BOP as a whole is unable to achieve this medical staffing
goal, as only 24 institutions had a medical staffing rate of 90 percent or higher as
of September 2014.6 Further, 12 institutions were medically staffed at only
71 percent or below, which the BOP’s former Assistant Director for Health Services
and Medical Director described as crisis level.7
The Office of the Inspector General’s (OIG) previous report on the BOP’s
aging inmate population found that understaffing in institutions’ health services
units limits inmate access to medical care, results in an increased need to send
inmates outside the institution for medical care, and contributes to increases in
medical costs.8 Moreover, the BOP’s staffing shortages continue despite significant
increases in its spending on medical care.9 The BOP’s spending on medical care
increased 21 percent, from $905 million in FY 2010 to $1.1 billion in FY 2014, while
5

This reflects the pre-trial and sentenced population in BOP-managed institutions only.
Inmates in contract institutions and residential reentry centers are excluded.
6

BOP, Program Statement 3000.03, Human Resource Management Manual (December 19,
2007). Vacancy rates are calculated as a percentage of positions assigned to an institution.
At a meeting to discuss a working draft of this report, the BOP’s Assistant Director for Human
Resource Management said that while the BOP advocates for institutions to fully staff their medical
positions, budgetary realities often make this unachievable. As a result, the BOP’s Central Office
recognizes that institutions must balance staffing needs in all aspects of institution operations.
7

This official oversaw the BOP’s medical care of inmates during our review, but retired in
October 2015.
8

DOJ OIG, The Impact of an Aging Inmate Population on the Federal Bureau of Prisons,
Evaluation and Inspections Report 15-05 (May 2015). See
https://oig.justice.gov/reports/2015/e1505.pdf (accessed February 8, 2016).
9

In 1994 the Government Accountability Office (GAO) reported that the BOP acknowledged
nursing staff shortages but was unable to recruit staff to fill the positions because its salaries were
well below that offered in the community. GAO, Bureau of Prisons Health Care: Inmates’ Access to
Health Care is Limited by Lack of Clinical Staff, GAO-HEHS-94-36 (February 1994).
In response to a working draft of this report, the BOP noted that other costs beside staffing,
such as the costs of pharmaceuticals and medical procedures, also contribute to increased medical
spending.

1


the BOP’s overall budget increased 11 percent over that time, from $6.1 billion to
$6.8 billion.
We conducted this review to build on our previous report’s findings by further
examining the BOP’s medical staffing challenges, as well as its use and
management of PHS officers as one means to address these challenges. In this
section, we describe the BOP’s responsibility to provide medical care to inmates in
its custody, the government-wide mission and role of the PHS, and the role of PHS
officers who provide medical care inside BOP institutions. In addition, we outline
the memorandum of understanding (MOU) between the BOP and the PHS and the
process used by BOP institutions to hire medical staff.
The BOP’s Responsibility to Provide Medical Care to All Inmates
The BOP is responsible for confining offenders in environments that are safe,
humane, cost-efficient, and appropriately secure. As part of this mission, the BOP
provides medical care to federal inmates.10 Federal inmates receive medical care
through institution health units or outside medical providers. In FY 2014, the BOP
employed 3,215 medical staff, including 2,382 civil servants and 833 PHS officers,
to meet this need. However, many institutions remain understaffed, limiting the
amount of care that an institution can provide. Specifically, in FY 2014, 20 BOP
institutions had a medical staff vacancy rate of 25 percent or higher and
3 institutions had a vacancy rate of 40 percent or higher. Hiring the medical
professionals necessary to maintain the care that institutions must provide has
proved challenging for the BOP. We discuss these challenges later in this report.
Established Health Units in Each BOP Institution Provide Medical Care
To provide medical care to inmates, every BOP institution operates a health
services unit. Most units have examination rooms, treatment rooms, dental clinics,
radiology and laboratory areas, a pharmacy, and administrative offices. The BOP
staffs these health units with medical professionals who provide urgent and routine
medical care on an ambulatory or observation basis. These medical professionals,
who may be either civil service employees or PHS officers, include physicians,
dentists, nurses, pharmacists, and mid-level practitioners.11 (See Figure below.)
For inmates who require more intensive, specialty care than the health services
units can provide, the BOP seeks care outside the institution.12

10

We conducted a broad review of the BOP’s management of inmate medical care in 2008.
See DOJ OIG, The BOP’s Efforts to Manage Inmate Healthcare, Audit Report 08-08 (February 2008),
https://oig.justice.gov/reports/BOP/a0808/final.pdf (accessed February 8, 2016). 
11
The BOP also contracts with medical providers to offer clinics and specialty services inside
the institutions to complement the primary care offered by the civil service and PHS-employed staff.
12
For outside medical care, the BOP signs contracts with community hospitals and physicians
with close proximity to the institution. The BOP negotiates rates with community hospitals using
comprehensive medical contracts whenever possible. The OIG is currently conducting a related review
of the effect of these rates on the BOP’s budget.

2


Figure

BOP Medical Staff, Fiscal Year 2010 to Fiscal Year 2014


Number of Health Services Staff

3500
3000
2500
2000
PHS
1500

Civil Service

1000
500
0
2010

2011

2012

2013

2014

Source: BOP staffing data

Civil service employees constitute the majority of health services staff. The
BOP uses recruitment, retention, and relocation incentives to entice civil service
medical professionals to join the BOP. Typically, the BOP uses incentives for
positions that are critical for the operation of health services units or for those that
are difficult to fill, allowing the BOP more flexibility in compensation. For example,
the BOP can use a recruitment bonus to increase an employee’s annual rate of pay
up to 25 percent, in exchange for a 2-year service commitment.13 The BOP also
uses retention bonuses, relocation bonuses, student loan repayments, annual leave
credits, and “above the minimum rate” pay to incentivize employment.14 When
using any incentive, an institution must prepare a narrative showing that it has a
great need for the employee, and that without the incentive the institution would
lose an existing employee or be unable to fill a vacancy.15 Officials in the BOP’s
Central Office must approve all incentives before they can be paid to employees.16
13

In response to a working draft of this report, the BOP noted that the BOP Director may
approve a shorter service agreement for recruitment bonuses.
14

Relocation bonuses are offered to current BOP employees who relocate to a hard to fill
location. Student loan repayment can be awarded up to $10,000 annually for loans covering
education required for a position, such as a loan to pay for medical school. Annual leave credit
increases the rate at which one earns annual leave each pay period. “Above the minimum rate” pay
allows an agency to pay a new employee above the initial grade and step that would normally be
required by the GS scale to meet the superior qualifications of a candidate.
15

The narrative includes information such as the qualifications needed for the position, the
qualifications of the candidate, labor market factors that that affect the ability to recruit, and recent
turnover, if any.
16

The type of incentive determines whether BOP officials in the Health Services Division or
Human Resource Management Division approve the incentive.

3


PHS Officers Compose the Remainder of the Health Services Staff
In FY 2014, 833 of the BOP’s 3,215 health services staff at the institutions
(26 percent) were PHS officers.17 The PHS is led by the Surgeon General and is an
agency of the U.S. Department of Health and Human Services. The PHS has
commissioned over 6,500 officers who are assigned to 23 federal agencies and the
District of Columbia.18 PHS officers serve in a variety of positions, treating
underserved and vulnerable populations in the areas of public health. The
underserved communities that PHS officers treat include populations such as federal
inmates or Native American communities living on remote tribal lands. Most PHS
officers are involved in medical care delivery, disease control and prevention,
biomedical research, treatment of mental health and drug abuse, or disaster
response efforts. Within the BOP, PHS officers work both in positions that provide
direct clinical care to inmates and in medical care management.
The PHS is part of the uniformed service rather than the civil service. As
such, PHS officers operate under a separate personnel system with additional
obligations, and they are paid according to the Uniformed Service Compensation
table used for the military rather than the General Schedule table used for civil
service employees. In exchange for their willingness to serve, PHS officers also
receive uniformed service benefits, including health insurance at no expense, taxfree housing and subsistence allowances, and access to military base facilities. The
PHS also offers 30 days of vacation per year, financial support for education
through the Post-9/11 GI Bill, access to the U.S. Department of Veterans Affairs’
home loan program, and retirement eligibility benefits after 20 years of service.
With these benefits come additional responsibilities, such as being on call at
all times and deploying on critical public health missions. PHS officers are
considered available for duty at any time and are therefore not eligible to earn
overtime pay. The PHS has several types of response teams that can immediately
deploy to regional, national, and international public health emergencies, such as
Hurricane Katrina or the Liberian Ebola crisis. Additionally, PHS officers must
continue medical education and maintain professional competence through
additional training and certifications.
The BOP’s partnership with the PHS to provide medical care to underserved
inmate populations dates back to the BOP’s creation in 1930. In 1991, the BOP and
the PHS signed an MOU to establish the conditions, responsibilities, and procedures

17

The BOP also employs both civil service and PHS officer health services staff in its Regional
Offices and Central Office. However, for this review we focused only on health services staff in the
institutions.
18
Some of these agencies include the BOP, the U.S. Marshals Service, the Food and Drug
Administration, the Indian Health Service, the Centers for Disease Control and Prevention, the
National Institutes of Health, the Department of Defense, and the District of Columbia Commission of
Mental Health Services.

4


that would guide PHS officers working throughout the BOP.19 Under the terms of
the MOU, the BOP annually notifies the PHS of the number of PHS officers it needs
and is responsible for the cost of PHS officer compensation and benefits. The BOP
transfers funds to the PHS for this purpose quarterly, and the PHS in turn pays and
manages PHS officer benefits using these funds.
Civil Service Employees and PHS Officers Are Considered Equally for Vacant
Positions, and Fill the Same Duties Once Hired
The BOP delegates the hiring of health services staff, including PHS officers,
to each BOP institution, with selection authority for most BOP institution staff
delegated to the institution’s Warden.20 Consequently, individual institutions
advertise vacancies and institution staffs focus their recruitment efforts primarily on
the local community surrounding each institution.21 Although civil service
employees and PHS officers have two separate personnel systems, their position
duties and responsibilities at the BOP are the same. Hiring officials told us they
select and hire qualified candidates without differentiating between the civil service
and the PHS, primarily because the need for such staff is greater than the
availability of candidates from either type. One institution’s Human Resource
Manager told us, “Whoever comes to us, however we get that person, if they are a
civilian, and we can meet their needs, we’re taking them. If they are PHS, and we
can meet their needs, we are taking them. Medical is so hard for us to recruit and
hire. If you bring us your credentials and say you’re willing to work here, we’ll
figure it out.”
During our review, BOP officials also described the challenges that can arise
from having to integrate these two separate personnel systems into their health
services operations to provide inmates with medical care. Among the relevant
differences we identified were leave policies, awards, drug testing, and training
opportunities. BOP officials also described how this problem is exacerbated by what
they see as discordant legal decisions in response to grievances from unionized BOP
employees on the one hand, and PHS officers on the other hand, over issues
relating to relative seniority between the two groups. While we did not focus our
review on these challenges, we did note that several BOP officials described the
inevitable tensions that can arise in a workforce where staff members share the
19
The relationship between the BOP and the PHS is also defined by statute. See
18 U.S.C. § 4005 and 42 U.S.C. § 250. In response to a working draft of this report, the PHS noted
that these two statutes underpin the MOU.
20

The Warden has selection authority for all institution staff below the assistant department
head level and for medical officers and dental officers in consultation with the BOP Medical Director.
This encompasses all staff members who provide medical care to inmates. See BOP, Program
Statement 3000.03, section 250.1.
21

The BOP also advertises nationwide job announcements for some positions, such as nurses.
However, applicants select their preferred locations as part of the online application process. When
institutions have vacancies in positions that were advertised under a nationwide job announcement,
the institution receives only the names of applicants who selected as a preferred location the
institution.

5


same jobs, workplace, and mission, yet can receive meaningfully different
compensation and benefits.22
Scope and Methodology of the OIG Review
Our review examined the BOP’s medical staffing challenges and its use of
PHS officers to address those challenges. We also evaluated the BOP’s ability to
transfer PHS officers to different locations based on staffing needs. We analyzed
BOP staffing data for both civil service employees and PHS officers from FY 2010
through FY 2014. Specifically, our review focused on medical professionals and
those employees who help the BOP provide direct care inside BOP institutions. For
the purposes of this review, we excluded all other staff. We also analyzed the cost
data associated with BOP civil service.
Our fieldwork, which we conducted from April 2015 through October 2015,
included interviews, data collection and analyses, and document reviews. We
interviewed BOP Central Office officials in the Administration, Human Resource
Management, and Health Services Divisions, as well as an official in the BOP’s
union. We also interviewed an official in the PHS Division of Commissioned Corps
Personnel and Readiness. We used video teleconference to conduct site visits to
five BOP institutions and to interview institution officials. A detailed description of
the methodology of our review is in Appendix 1.

22

In Appendix 1, we describe the extent to which we examined these issues, and our decision
to focus the review on medical staffing challenges, in more detail.

6


RESULTS OF THE REVIEW 

The BOP’s Compensation and Incentives Offered to Civil Service Medical
Staff Are Not Sufficient to Alleviate Staffing Shortages
Despite the BOP’s increased use of incentives for civil service employees, the
BOP remains challenged to recruit and retain medical professionals. Specifically, we
found that the salaries and incentives the BOP offers are not competitive with those
of the private sector, particularly given the need for the BOP to compensate its
employees for the safety and security factors intrinsic to working in a correctional
setting. As of September 2014, the BOP was operating at an 83 percent medical
care staffing level, 7 percent below its goal of 90 percent. As a result, health
services units are left understaffed, with increased workloads that limit the amount
of medical care that can be provided inside an institution. The BOP's resulting need
to rely on temporary duty (TDY) assignments shifts its staffing resources among
institutions, and its reliance on contractors to augment the medical care it can
provide contributes to the BOP’s overall spending on outside medical care.
The BOP is Disadvantaged in Its Efforts to Recruit Civil Service Medical Professionals
While recruitment is a challenging area for many healthcare organizations, it
is particularly challenging for the BOP because of its geographic locations and local
market competition, the limits on the pay it can offer its medical staff, and its
correctional setting.23 The BOP’s Assistant Director for Human Resource
Management said that recruitment is also difficult because the recruiting challenges
the BOP faces vary across institutions. As of September 2014, there were
121 BOP-managed institutions located across the United States, in both urban and
rural areas.
We found that in major metropolitan areas, the BOP’s greatest recruiting
challenge is attracting candidates that are also qualified to work in private
organizations, such as hospitals and local medical centers. For example, at one
institution with several major universities in the surrounding area, the BOP has
been unable to attract recent graduates who are willing to occupy entry-level
positions. The Human Resource Manager of that institution told us that the major
universities have more prestigious medical facilities and offer higher pay.
At the BOP’s more rural locations, we found that the remoteness of the
institution often deters medical professionals. A Warden at a more remote
institution said that because the area is isolated, most medical professionals are in
the area only to work at a particular, respected community hospital. Staff at
another institution told us that being in close proximity to a respected community
23

In response to a working draft of this report, the BOP noted that there are shortages of
medical professionals in a variety of fields, making its challenges not unlike those the general medical
community faces.

7


hospital is both good and bad overall, but definitively unhelpful to recruiting. While
the institution can use the hospital for services that cannot be provided inside the
institution, it becomes nearly impossible to compete with the hospital for staff,
because of the hospital’s favorable reputation and higher pay. An Associate
Warden at another institution told us that when competing with other organizations,
the institution is often unable to attract candidates. He said that when the
institution is able to hire employees, they typically leave shortly after they are hired
for more lucrative offers.
Position Grades and Compensation, Even with Incentives, Are Not Competitive with
Local Markets
In many instances, regardless of location, the federal limits on pay and
incentives that hiring officials can offer potential employees pose a significant
challenge for BOP institutions. BOP hiring officials we interviewed told us that the
compensation offered is not enough to competitively attract or retain medical
professionals. We found that this is especially true for the positions, such as
doctors, pharmacists, and dentists, which are necessary to operate health units.
The BOP is required to classify positions according to the General Schedule
(GS) pay scale, and, for physical therapists and pharmacists especially, we found
the BOP struggles to offer competitive pay because the assigned grade of the
positions limits the salaries they can offer.24 According to the BOP’s Chief of Health
Services Staffing and Recruitment, the current grade of physical therapist and
pharmacist positions on the GS scale makes it very difficult to hire individuals into
civil service positions.25 Rather, as of September 2014, the majority of medical
professionals in those positions at BOP institutions are PHS officers. According to
BOP officials, this is because the GS grade levels the Office of Personnel
Management (OPM) assigned to these civil service positions are too low and the
PHS compensation and benefits are more attractive in comparison. A Warden told
us that if the BOP could offer more competitive pay through the civil service, it
would be in a much better position when it comes to recruitment.
The BOP’s Chief of Health Services Staffing and Recruitment said that
attracting candidates for most medical positions in a correctional setting already
requires the use of incentives. However, we found that even with incentives, the
BOP cannot offer competitive salaries because of the limitations imposed by the
current GS pay scale. Using data from the BOP, OPM, and the Bureau of Labor
Statistics (BLS), we found that there is a large gap between the salaries the BOP
pays its medical employees and those offered for similar positions in the local areas
24

The General Schedule is the position classification and pay system governing the majority
of salaried personnel positions within the civil service. OPM is responsible for administering the GS
classification standards, qualifications, and pay structure.
25
Further, he said that most physical therapist positions are at the doctorate level and the
BOP’s current classification of this position does not account for that. In response to a working draft
of this report, the BOP said that this is because the BOP must follow OPM’s Classification Standards, in
accordance with 5 U.S.C. Chapter 51.

8


surrounding institutions.26 For example, the BLS reports that the average salary for
a nurse in the local area is 34 percent higher than step 1 of the highest grade for a
BOP nurse. We found that the gap widens for other positions, with a 60 percent
difference for physicians, a 102 percent difference for pharmacists, and a
133 percent difference for dentists.27 We also found that the salary gap was
significant in both rural and metropolitan areas. (See Table 1 below.)
Table 1

OPM and the BLS Salary Comparison in Rural and Metropolitan Areas, 

FY 2014

Rural Area
Nurse

Top GS
Grade,
Step 1

BLS
Average

Percent
over
BOP

Metropolitan
Area

$47,923

$61,110

28%

Nurse

$114,872

$187,734

63%

Physician

Pharmacist

$57,982

$120,241

107%

Dentist

$69,497

$170,508

145%

Physician

Top GS
Grade,
Step 1

BLS
Average

Percent
over
BOP

$51,723

$77,468

50%

$123,981

$192,476

55%

Pharmacist

$62,579

$120,034

92%

Dentist

$75,008

$159,368

112%

Note: This table does not include special pay. See footnotes.
Sources: BOP spending data, BLS occupational employment statistics, and OPM classification
standards and locality pay tables

The BOP’s Assistant Director for Human Resource Management told us that
the GS scale does not meet the BOP’s current needs because the assigned grades
of many medical positions are too low. The BOP’s former Assistant Director for
Health Services and Medical Director told us that the system is antiquated and no
longer reflects today’s reality or position requirements. The BOP’s Personnel
Director told us that OPM convened a workgroup to rewrite the classification
standards for nurses across the federal government. However, we found that the
BOP’s discussions with OPM to restructure position classifications have not produced
results. The Assistant Director for Human Resource Management said that the lack
of change was frustrating because nurses, for example, qualify only for a GS-5
classification, which is not competitive.28
26

For this analysis, we used the GS scale and step 1 of the position’s highest grade to
balance the variance in staff pay based on their status as a new versus more experienced employee.
For example, OPM classification standards state that a non-supervisory pharmacist can be grade 7, 9,
or 11, so we used grade 11, step 1 for our analysis. Neither the OPM data nor the BLS data includes
the value of benefits in their calculations. See Appendix 1 for more information.
27

This analysis does not include special pay. OPM establishes special pay at a rate higher
than basic pay for a group or category of positons in certain geographic locations where there are
significant hiring challenges. We found that even when accounting for salary increases from special
pay, the gap between the BOP and the local area remains large. For example, in Lexington, Kentucky,
a dentist with special pay can earn $78,000 in the BOP while the BLS average is $176,000. The BOP’s
Assistant Director for Human Resource Management said, “OPM works with the BOP on special salary
rates but it’s a Band-Aid on a much bigger issue.”
28

According to the 2015 GS pay table, the base salary of a GS-5 position is $27,982. This
figure does not account for locality pay.

9


Position classifications are also problematic for mid-level practitioners such as
physician’s assistants and nurse practitioners. The BOP’s former Assistant Director
for Health Services and Medical Director said that mid-level practitioners are
significantly underpaid and that even incentives do not address the pay disparity.
For example, the Health Services Administrator at one institution in need of a nurse
practitioner told us it has been unable to fill the vacancy because the salary is not
commensurate with the education and experience required. Specifically, she said
that one of the nurse practitioner applicants to her institution had 6 years of
education, but the BOP could offer only a GS-9 salary.29 In comparison, she further
said that the BOP could offer a similar salary to a paramedic even though, in her
state, paramedic qualifications can be obtained with less education. Citing
anomalies such as these, the BOP’s Assistant Director for Human Resource
Management described the GS scale as a one-size-fits-all system that does not
always fit everyone.
In addition, we found that the private sector pays medical professionals who
are not working in correctional settings significantly more than BOP civil service
employees in the same positions, indicating that the salaries the BOP offers do not
factor in the fact that its employees face inherent security risks associated with
working in a correctional setting. The BOP’s Assistant Director for Human Resource
Management said that many medical professionals do not find working in a
correctional setting appealing because it is vastly different from a hospital. The
BOP’s former Assistant Director for Health Services and Medical Director agreed,
saying not everyone wants to work in a place that could present a threat to his or
her well-being. Despite this challenge, the BOP tries to market the benefits
associated with working in a correctional setting. As law enforcement officers, all
BOP employees gain access to the law enforcement federal retirement system,
health benefits, and annuity. Still, the compensation offered to the BOP’s medical
professionals is less than what is offered in the local community hospitals and
medical centers where there are fewer safety risks.
Since FY 2010, the BOP Has Increased Its Use of Incentives to Recruit and Retain
Civil Service Medical Employees
Like most other federal agencies, the BOP must operate within the GS scale
and is limited in what it can offer potential employees by the grade and
classification of the position. However, when the requirements and responsibilities
of a position warrant more compensation than its grade and salary, the BOP can
supplement compensation with various incentives. According to BOP data, from
FY 2010 to FY 2014, the BOP consistently used incentives for positions for which it
had the greatest needs, including clinical nurses, general practice medical officers,
and mid-level practitioners. The BOP’s Assistant Director for Human Resource
Management, who has been with the BOP for 27 years, said that the BOP did not
regularly need to use incentives until approximately 2000. He said that now the
BOP encourages institutions to be aggressive in recruiting for positions that have
29

According to the 2015 GS pay table, the base salary of a GS-9 position is $42,399. This
figure does not account for locality pay.

10


been difficult to staff and to offer as much as they can for an acceptance. We found
that more institutions have been requesting incentives to help attract medical
employees who provide direct clinical care. For example, in FY 2010, 70 percent, or
65 of 93 BOP institutions, requested incentives for their medical employees.30 We
found that this increased to 89 percent in FY 2014, when 87 of 98 institutions
requested incentives.
Consequently, from FY 2010 to FY 2014, the number of BOP medical
employees receiving at least one incentive increased 74 percent. Specifically,
during FY 2010, the BOP awarded 409 incentives to medical employees, including
219 monetary incentives that were valued at $2.7 million.31 During FY 2014, the
BOP awarded 712 incentives, including 342 monetary incentives that were valued
at $4.5 million.32 (See Table 2 below.)
Table 2

Incentives Awarded by Fiscal Year and Type, in Thousands

Fiscal
Year

Recruitment
Bonus

Relocation
Bonus

Retention
Allowance

Student
Loan
Repayment

Above
Minimum
Rate

Annual
Leave
Credit

104

4

80

31

93

97

409

$1,445

$60

$932

$279

—

—

$2,716

101

5

140

96

146

224

712

$1,752

$77

$1,793

$900

—

—

$4,522

2010

2014

Total

Notes: Monetary totals are in thousands. As noted above, “above the minimum rate” pay allows an
agency to set higher pay to meet the superior qualifications of a candidate or the special need of an
agency.
Source: BOP incentives data

According to BOP data, institutions frequently use recruitment and retention
bonuses as incentives. Table 3 below shows our analysis of the incentives offered
to employees in positions with the greatest pay disparity when compared to the
BLS average. As noted above, special pay and incentives can help lessen the gap;
but overall, BOP salary averages remain low in comparison for recruitment.

30

The BOP maintains data on correctional complexes in the aggregate, rather than separately
for each institution within the complex. As a result, the total number of locations requesting
incentives is less than the overall total of 121 institutions.
31

Of the 409 incentives the BOP awarded, 190 were for annual leave credit or above the
minimum rate pay. The BOP does not assign monetary value for these incentives because they vary
substantially by employee rate of pay. For example, hiring officials can increase an employee’s leave
accrual rate from 4 hours per pay period to either 6 or 8, but the monetary value of that leave would
depend on his or her salary.
32

Of the 712 incentives the BOP awarded, 370 were for annual leave credit or rate of pay
above the minimum.

11


Table 3

Incentives Awarded by Position, FY 2014, in Thousands

Student
Loan
Repayment
Total

Incentives
Total

Average
Monetary
Incentives
per person

$227

$102

$932

$7

$25

$480

$63

$982

$15

$10

—

$59

—

$69

$12

$196

—

$280

$40

$516

$20

Recruitment
Bonus
Total

Relocation
Bonus
Total

Nurse

$603

—

Physician

$414

FY 2014

Pharmacist
Dentist

Retention
Allowance
Total

Notes: Totals are in thousands. For analysis, the category “Physician” combines data for general
practice medical officers, internal medicine medical officers, and general medical officers.
Source: BOP incentives data

For many nurses and medical doctors, student loan repayment is also an
attractive incentive. However, the BOP’s Assistant Director for Human Resource
Management said that for the BOP, student loan repayment is limited to $10,000
per employee each year.33 An additional incentive the BOP can use for some
positions is accelerated promotion, which shortens the amount of time between
salary increases. Yet, these incentives, while helpful, have not resulted in bringing
BOP medical staffing to sufficient levels. A Health Services Administrator told us
that her institution recently hired a Chief Dentist after 4 years of vacancy and was
able to do that only by offering multiple incentives. The Human Resource Manager
at another institution told us that he uses a combination of incentives but even with
multiple incentives, recruitment is still difficult.
We also found that institution efforts to obtain approval to use incentives are
time-consuming, which sometimes results in the BOP losing candidates to other
employers; but Central Office and institution staff do not agree on the reason for
the delays. Central Office staff attributes the long approval process to institution
Human Resource Managers’ lack of information and knowledge of the requirements
for processing incentives. The BOP’s Chief of Health Services Staffing and
Recruitment said that institution Human Resource Managers deal with labor
relations issues, grievances, performance, and the Union, and that medical
recruitment is just one small piece of the puzzle. However, an institution Health
Services Administrator told us that the paperwork required to process each one is
extremely cumbersome.
The BOP’s incentive approval process requires that each incentive be
processed separately, even when a single employee will be receiving multiple
incentives. BOP officials told us that institution staffs wait for incentives to reach
the final stages of approval at the BOP’s Central Office before offering them to
33
Federal law imposes a $10,000 annual cap per employee and an overall cap of $60,000 per
employee. See 5 U.S.C. § 5379(b)(2). The BOP’s Assistant Director for Human Resource
Management also noted that medical school loans are often in the range of six figures and that the
amount of student loan repayment the BOP can offer does not compare to that of the private sector.

12


potential candidates because they are unsure which incentives they can
authoritatively present to candidates prior to confirmation. For example, a Human
Resource Manager told us that because incentives are not final until approved, he
has little room for negotiation and that what he can offer in competition with the
local market is initially hypothetical. The BOP’s Personnel Director acknowledged
that institution hiring officials lack confidence that incentives will be approved. But,
he told us, institutions should offer all they can because in practice incentives are
rarely denied. The BOP has considered automating the incentive approval process
by creating a standard template for every incentive. According to the BOP’s
Personnel Director, through automation, incentives would be approved more quickly
and more information regarding incentive availability would be accessible.
However, the BOP has not yet implemented this change.
Because Incentives Are Not Always Enough, the BOP Has Sought Other Alternatives
to Attract Medical Professionals
The BOP supplements its use of incentives with other alternatives that also
have the effect of increasing pay. One of these is the Physicians and Dentists
Comparability Allowance Program (PCA Program).34 The PCA Program allows the
BOP to adjust physician and dentist compensation up to $30,000 when it faces
difficulty in recruiting.35 The adjustment for each employee is determined through
negotiation with that employee and the BOP Medical Director’s approval of the
employee’s credentials. Eligible physicians or dentists must also enter a 1- or
2-year service agreement with the BOP. The BOP’s former Assistant Director for
Health Services and Medical Director told us that this program generally makes the
civil service a more lucrative option for physicians.36 However, the higher salary
potential under the PCA Program is not always lucrative enough for other positions,
such as psychiatrists.
The BOP recently received approval from the Justice Management Division
and OPM to determine pay for psychiatrists using the laws governing medical
professional compensation in the U.S. Department of Veterans Affairs (Title 38).37
Under Title 38, the BOP can increase an individual’s compensation package up to a
maximum of $260,000 per year, based on his or her rating from an approval
34

5 U.S.C. § 5948(a).

35

Recruitment difficulty is determined by a number of factors, including length of position
vacancy, number of unqualified applicants, number of interviewed but underqualified applicants, and
number of physicians rejecting offers of employment and citing inadequate compensation as the
reason.
36

Physicians and dentists can earn up to $203,000 in annual salary under the PCA Program.

37

The Justice Management Division provides senior management guidance as it relates to
DOJ policy for all matters pertaining to organization, management, and administration.
A majority of employees of the federal government are employed under personnel laws
contained in Title 5 of the United States Code, which covers administrative law. Title 38, the section
of federal law covering veterans’ benefits, includes an alternate personnel system for specific
occupations such as medical professionals. Under Title 38, employees are paid under separate pay
schedules and pay is determined under rules separate from Title 5.

13


panel.38 The panel will determine the salary for each individual from tiers that the
Department of Veterans Affairs has established based on resume, tenure, and
certifications. The BOP is also working with the National Finance Center to modify
the system for salary payment processing and anticipates implementing Title 38
authority in the spring of 2016. If the initiative is successful, the BOP told us it will
consider expanding Title 38 to other positions that are difficult to staff, such as
pharmacists. BOP officials said that initially there would be minimal budgetary
impact because the BOP employs relatively few psychiatrists, but that future
budgets would need to incorporate increased costs if the principles of Title 38 were
extended to more professions.39
Another benefit available to some BOP medical personnel is the opportunity
to convert to the PHS from the civil service. A PHS officer we interviewed told us
that she originally took a pay cut when she joined the BOP as a civil service
employee, but did so with the prospect of converting to the PHS for greater
uniformed service benefits.40 She said that she also began her career as a civil
service employee and converted to the PHS because the compensation package was
more lucrative.41 For positions such as registered nurses and pharmacists, for
which the BOP is not able to offer competitive salaries within GS constraints, we
found PHS officers are likely to fill these positions. In particular, the BOP’s
Assistant Director for Human Resource Management said that the BOP staffs a high
number of PHS pharmacists because the BOP cannot offer a comparable salary for
pharmacists. In FY 2014, 145 of 194 pharmacists (75 percent) at BOP institutions
were PHS officers, rather than civil service employees.42
The PHS accepts applications for a commission during defined periods
throughout the year, which vary by profession. The PHS accepts applications from
physicians and dentists at any time, but accepts applications from other professions
only during limited windows during the year.43 The PHS allows agencies employing
38

The panel will include representatives from the BOP’s Health Services Division, the BOP
Union, and medical doctors.
In response to a working draft of this report, the BOP estimated that typical compensation
packages would not exceed $240,000 per year based on individual factors.
39

The BOP reported that, as of November 2015, it employed 25 psychiatrists.

40

The BOP allows qualified and eligible employees to convert to the PHS personnel system as
long as their application for a commission is approved by the PHS.
41

We attempted to compare compensation in the GS and PHS systems but determined that
we could not do so because the process of setting PHS officer pay is more individualized than the
process of setting civil service employee pay. For additional information, see Appendix 1.
42
We also found that the appeal of joining the PHS is lower when civil service salaries become
more competitive. The Chief of the BOP’s Staffing and Recruitment Section told us that a majority of
BOP dentists used to be PHS officers until the BOP decided to increase the position grade for dentists.
Since that change, he said, he has seen an increase in the number of BOP dentists who are civil
service employees.
43

In previous years, the PHS application process was open to all professions at all times. In
2010, the PHS streamlined the application process to allow applications only from certain professions
at certain times throughout the year. For example, in 2015, the PHS opened its application process to
(Cont’d.)

14


its officers a limited number of waivers that can be submitted outside of the normal
application window for applicants that are deemed critical by the agency. However,
the BOP’s PHS Liaison told us that if an employee stationed at an institution that is
already well-staffed wants to convert to the PHS, he or she must transfer to a
location where there is a shortage of medical staff. The BOP’s former Assistant
Director for Health Services and Medical Director said that because the PHS does
not commission many new officers during the regular application windows, waivers
are consequently very valuable tools. However, the number of waivers the PHS
allocates to the BOP each year remains limited: 15 in 2014 and 17 in 2015. At
institutions with several vacancies, or at new institutions, the BOP will offer
conversions to the PHS as an incentive to transfer between institutions or to stay
with the agency. Institution staff we interviewed acknowledged that being able to
offer the option to convert to PHS is a recruitment tool they could use for hard to fill
positions. We discuss the BOP’s management of PHS officers in more detail below.
Institutions Must Rely on TDY Assignments and Contracted Medical Care because of
Continuous Understaffing
The BOP’s inability to recruit and retain medical professionals has led to
institutions operating at unfavorable staffing levels. Institution staff told us that
when staffing levels are low they depend on TDY assignments and medical
contractors for assistance. The BOP uses TDY and Regional Medical Assistance
Support Teams to provide additional resources to its six regions. These teams were
created in 2011 to assist institutions with critical medical staffing needs. According
to BOP officials, these teams are used when institutions’ health services units are
30 to 40 percent understaffed. Both civil service employees and PHS officers serve
on Regional Medical Assistance Support Teams and enlist on weeklong TDY
assignments to assist. An official at one institution in particular told us that even
with PHS officers on staff, it relies on TDY from other institutions to accomplish its
mission. In FY 2014, this institution had a vacancy rate of 21 percent for medical
professionals. However, according to institution staff, relying on TDY for support is
a temporary fix and should not replace a permanent solution for staffing shortages.
The BOP’s Assistant Director for Human Resource Management told us that rather
than continuous TDY, it would be more beneficial for the BOP to pay an incentive to
hire a full-time employee. With this approach, fewer long-term expenses would
stem from the repetitive use of TDY.
We found that staffing shortages lower staff morale, increase staff workload,
and ultimately can reduce inmates’ access to routine medical care. A Human
Resource Manager told us that because correctional settings require around-theclock staffing, all vacancies affect staff morale. He said that because operations
never cease, the lower the staffing levels, the greater the need to use mandatory
overtime and double shifts. Additionally, staffing shortages increase the workload
of those remaining staff. The BOP’s PHS Liaison told us that when there are
vacancies, the existing staff becomes overworked. A Physician’s Assistant told us
pharmacists only during the month of August. The BOP PHS Liaison told us that the new application
process limits the number of applications the PHS processes each year.

15

that increased workloads can easily drain staff, which, for him, makes some of the
routine care a lower priority. A Health Services Administrator also told us that
when health units do not have the staff to see inmates, they have to send them
outside the institution for basic medical care because they are unable to meet their
needs inside the institution. The Warden at the same institution agreed, stating
that staffing shortages greatly increase outside medical trips, subsequently
resulting in an increase in outside medical spending.
Staff vacancies have an adverse impact on institution health services units
and ultimately increase the BOP’s outside medical spending when care cannot be
provided inside the institution. In FY 2014, the BOP spent $60 million in overtime
payments to salaried employees to transport inmates outside the institution for
medical care, an increase of 22 percent from the $49 million spent in FY 2010.
While acknowledging that the BOP faces many challenges to recruit and retain
medical staff, particularly because of the geographic locations of institutions, the
limitations of the GS scale, and the prison work environment, we believe the BOP
could be doing more to proactively identify and address its medical staff vacancies.
In the remainder of this report, we discuss strategies the BOP could adopt to
address these challenges.
The BOP Does Not Identify or Address Recruiting Challenges in an Agencywide and Strategic Manner
The BOP delegates many of the actions necessary for recruiting and hiring
medical staff to its individual institutions. These actions include conducting
recruitment activities in the local labor market, advertising vacancies, interviewing
candidates, preparing incentive request paperwork, and managing the institution’s
staffing budget. As a result, the BOP’s actions to address its recruiting challenges
tend to involve reactively addressing specific problems faced by individual
institutions rather than proactively identifying, prioritizing, and responding to
regional or national trends in a coordinated fashion across all of its institutions.
At the Central Office level, the BOP’s Health Services Division has a Staffing
and Recruitment Section that has both short-term and long-term responsibilities.
In the short term, the section is responsible for understanding institutions’
immediate medical staffing needs, explaining to institution human resources staff
the incentives available for medical professionals, and guiding medical professionals
through the BOP’s hiring process. In the long term, the section is responsible for
increasing the pool of medical professionals who are interested in BOP vacancies.
The section does not advertise vacancies or make hiring decisions; these actions
are delegated to each institution. Further, the Chief of Health Services Staffing and
Recruitment told us that institutions must request the section’s assistance in
addressing recruiting challenges. Even when an institution requests assistance, it is
not required to follow the section’s guidance. This reactive, locally delegated
response to recruitment challenges has prevented the BOP from assessing which
vacancies have the greatest negative impact on its ability to adequately provide
medical care to inmates.

16


We further found that, even when the BOP has taken steps to address
recruitment challenges across all of its institutions, these efforts have not resulted
in a uniform approach to the issue. For example, officials throughout the BOP have
designated medical vacancies as hard to fill to justify their use of incentives to
enhance recruiting. However, we found that the BOP does not have a clear
definition of this term. As a result, it cannot easily describe the degree to which
any one position is hard to fill and it cannot use this designation to help it set
priorities among medical vacancies. To illustrate, BOP policy identifies the length of
time a position has been vacant as one factor that would justify using the
Physicians and Dentists Comparability Allowance Program (PCA Program), but it
does not give any guidance as to when the length of a vacancy should be
considered problematic.44 The Assistant Director for Human Resource Management
said that a position is considered hard to fill once the Human Resource Manager has
communicated to Central Office that all recruitment efforts, absent incentives, have
made hiring challenging. Yet one institution’s Human Resource Manager told us
that any position requiring an incentive is considered hard to fill, while a different
Human Resource Manager at another institution said that he considers a position
hard to fill if he does not receive any applications after two or three
advertisements. A third Human Resource Manager said that, on paper, none of the
positions at her institution is hard to fill; but she went on to tell us that they
experienced such difficulty trying to fill a psychiatrist vacancy that the BOP’s
Central Office eventually reallocated the position to a different institution.
We found that one primary obstacle to the BOP developing a truly proactive,
coordinated approach to addressing recruitment challenges is that it does not
analyze the data it already collects to assist it in identifying and prioritizing these
challenges across all of its institutions. For example:
	 Vacancy Data: The Central Office Staffing and Recruitment Section monitors
medical vacancies, but the Chief of Health Services Staffing and Recruitment
said that the data they monitor does not differentiate between positions that
are vacant because of recruitment challenges and positions that are vacant
for other reasons.45
	 Incentive Data: Although the BOP collects data on the use of recruitment
and retention incentives, which could help the BOP identify locations in which
institutions have difficulty filling medical vacancies, the BOP does not analyze
any of the data it collects on incentives for this purpose. The BOP’s
Personnel Director told us that the BOP reserves for Central Office officials
final approval authority for recruitment and retention incentives, instead of
44

BOP, Program Statement 6010.05, Health Services Administration (June 26, 2014),
paragraph 17f.
45

The Chief of Health Services Staffing and Recruitment explained that, because hiring
decisions are decentralized to the institution level, institutions sometimes freeze vacancies instead of
filling them to ensure that funds are available in the institution’s budget to cover overtime, outside
medical expenses, and other costs. He said that if an institution is not actively attempting to fill a
vacancy, he would not consider that position difficult to fill.

17


delegating that authority to Wardens, in part so that the BOP can collect data
on the use of these incentives.46 However, she also said that the BOP tracks
the use of incentives only to ensure that spending remains within budgetary
limits, and not for the purpose of helping to identify the hardest to fill
vacancies in the BOP system.
	 TDY Assignment Data: The former Assistant Director for Health Services and
Medical Director told us that when an institution resorts to requesting TDYs,
it is usually because it cannot find anyone to fill the vacancies it is
advertising. Data on institution requests for support through TDY
assignments could therefore help the BOP’s Central Office identify institutions
that are struggling to find permanent staff; but this information is not
available at the Central Office level because the Regional Offices manage TDY
requests and assignments.
	 Outside Medical Care Cost Data: Our May 2015 review of the impact of an
aging inmate population found that understaffing in health services units
increases the need for
Budgetary Impact of Understaffing on Outside
outside care.47 The cost of
Medical Costs
this care varies because the
BOP signs a separate
We identified one complex for which medical
contract for each institution
staffing dropped from 35 of 46 positions filled
(76 percent) in FY 2010 to 25 of 42 positions filled
with local medical
48
(60 percent) in FY 2014. Of all BOP institutions,
Further, the
providers.
this institution paid the highest rates for outside
BOP’s care level system
medical care, with contract costs more than triple
means that inmates with
the Medicare rate. We looked at BOP spending
data and found that spending on outside medical
more significant medical
care at this complex increased 47 percent from
needs are concentrated in a
FY 2010 to FY 2014 (double the 23 percent increase
handful of institutions, with
in this spending seen by the BOP as a whole during
the result that staff
that same time). Given the relatively high cost of
vacancies at these
obtaining outside medical care in this location, a
more proactive assessment of staffing needs could
institutions can have a more
49
be beneficial to the BOP.
A
significant impact.
Health Services
Source: OIG analysis of BOP staffing data, contract
Administrator at a BOP
data, and spending data
46

In response to a working draft of this report, the BOP noted that the Department’s Human
Resources Order, DOJ 1200.1, states that approval of these incentives may not be delegated below
the Personnel Officer level. The BOP further noted that it is required to collect data on incentives to
fulfill reporting requirements to the Department and OPM.
47

DOJ OIG, The Impact of an Aging Inmate Population, 18.

48

These costs also vary depending on whether an inmate requires inpatient or outpatient

care.
49

The BOP assigns each inmate a care level from 1 to 4 based on documented medical
history, with Care Level 1 being the healthiest inmates and Care Level 4 being inmates with the most
significant medical conditions. The BOP also assigns each institution a care level from 1 to 4, based
on the institution’s level of medical staffing and resources. For more information about the BOP’s care
level system, see OIG, The BOP’s Efforts to Manage Inmate Healthcare.

18


medical center said that by assessing only staffing levels, the BOP overlooks
the needs of high care-level institutions. We believe this causes the BOP to
underestimate the value of filling priority vacancies at high care-level
institutions where a greater proportion of inmates are very ill. The Health
Services Administrator emphasized, “The Bureau [of Prisons] is sending us
the sickest of the sickest guys to take care of, and if we don’t have the staff
on board here to do even some of the basics that we need to do with them,
then we end up having to send them into the community to get it done.”
Because the BOP does not take these variations in medical need or medical
cost into account, it does not optimally prioritize filling the positions that cost
the most to leave vacant.
We found that the BOP has been aware for some time that its locally
delegated, reactive approach is ill suited for the medical staffing challenges it faces.
Yet it has also declined opportunities to establish a more coordinated, proactive
approach. Specifically, in June 2009, a BOP working group established to examine
the BOP’s medical recruitment challenges recommended that the BOP centralize
medical recruitment into the BOP’s Consolidated Employee Services Center in Grand
Prairie, Texas.50 The working group recommended centralization to improve
customer service to applicants and to manage many functions, such as preparing
incentive requests, that are the responsibility of institution staff. In support of its
recommendation, the working group wrote: “A dedicated section would allow the
agency to aggressively recruit and retain employees in an attempt to proactively
address staffing concerns, rather than reactively, which continues to hinder
effective operations and negatively impacts existing staff.”51 At its July 2009
meeting, however, the BOP’s Executive Staff decided not to approve any of the
options the working group developed.
The working group’s June 2009 findings included a section for comments
from the BOP divisions most likely to be affected by the working group’s proposals.
In its comments, the Health Services Division said that it could not support any of
the working group’s proposals for several reasons, including a belief at the time
that recruitment was improving and could be further enhanced through additional
resources rather than through reorganization. Instead, it recommended hiring
someone to verify the professional credentials of candidates for medical vacancies,
ensuring that they would be qualified to practice if offered a position. The former
Assistant Director for Health Services and Medical Director confirmed that the BOP
now employs a nurse for this purpose. The Health Services Division also
recommended hiring one medical recruiter for each of the BOP’s six regions to
target hard to fill locations, and the BOP reported that it hired the six regional
recruiters in the fall of 2015.
50
The Consolidated Employee Services Center centralizes some aspects of the hiring process
and provides guidance to the institutions on hiring procedures.
51
Facilitator, National Health Care Staffing and Recruitment Workgroup, BOP, Executive Staff
Paper, National Health Care Staffing and Recruitment Enhancement, June 9, 2009, 14. In addition to
its recommended option, the working group also researched and presented two other options in its
report.

19


Since the 2009 comments, however, we found that the health services
vacancy rate has actually risen at BOP institutions, from 15 percent in FY 2010 to
17 percent in FY 2014. The BOP’s decision to continue addressing its struggles with
medical recruitment by reacting to individual institution requests rather than by
developing a strategic, coordinated plan, has not led to improved results.
Meanwhile, spending on outside medical care has increased 23 percent, from
$351 million in FY 2010 to $434 million in FY 2014.
This lack of strategic planning also means that the BOP cannot fully take
advantage of an annual opportunity it has to articulate its staffing priorities to the
PHS. The memorandum of understanding (MOU) between the BOP and the PHS
requires the BOP to “notify PHS at least annually, and more frequently if necessary,
of the number of PHS Commissioned Officers, by training and experience, needed
to fulfill the requirements of BOP.”52 BOP officials told us that, while they respond
to the PHS annually with this information, they do not base their response on a
systemic assessment of the BOP’s medical staffing needs. Instead, they simply
report the number of PHS officers already employed in BOP positions. The former
Assistant Director for Health Services and Medical Director told us that he did not
think increasing the number reported would make a difference. However, we note
that the PHS already knows how many of its officers work for the BOP because it
pays PHS officers and manages their benefits using BOP funds.53 The PHS’s Deputy
Director of the Division of Commissioned Corps Personnel and Readiness (PHS
Deputy Director, DCCPR) told us that the PHS requests this annual projection of
need in order to help shape the Commissioned Corps’ annual recruitment plan and
support limited force planning.
We believe that the BOP is missing an important opportunity by providing the
PHS with data it has rather than conducting a robust analysis to determine what
kind of medical staffing its institutions need. If the BOP analyzed its recruitment
challenges and prioritized vacancies based on the impact those vacancies have on
the BOP’s ability to care for its inmate population, this could help the BOP articulate
specific numbers and types of PHS officers that would be of greatest benefit to
address its staffing challenges.
The BOP Does Not Use Its Authority to Assign PHS Officers to Positions
Based on Greatest Need
Both PHS policy and the PHS officers’ sworn oath give the BOP the authority
to place PHS officers in positions where they are most needed. PHS officer
appointees swear an oath that they are “willing to serve in any area or position or
wherever the exigencies of the Service may require.” However, the BOP does not
52
MOU between the BOP, DOJ, and the PHS, Department of Health and Human Services,
September 1991, paragraph III.B.
53
The BOP’s Chief of Budget Execution told us that every month the Department of Health
and Human Services generates a payroll report of PHS officers employed at the BOP, which the BOP’s
Budget Execution Office reconciles to ensure they transfer the appropriate amount of funds to the PHS
to pay for these salaries and benefits.

20


take full advantage of this flexibility because, as noted above, it does not address
recruitment challenges in a strategic, coordinated way and therefore does not place
PHS officers in positions that maximize their benefit to the BOP. In the section
below, we discuss options that the BOP might consider to increase the efficiency of
its assignment of PHS officers.
The PHS encourages its officers to pursue diverse work experiences
throughout their careers.54 To incentivize transfers, PHS promotion boards place
value on an officer’s mobility, with multiple moves expected of officers seeking
promotion to the higher ranks. The PHS’s Commissioned Corps Personnel Manual,
which governs human resources policy for PHS officers, gives the BOP authority to
initiate voluntary transfers to meet its needs or the needs of PHS officers. It also
gives the BOP the authority to initiate involuntary transfer of PHS officers at any
time to meet the BOP’s needs. We found that the BOP does not currently manage
these positions in ways that would encourage PHS officers who are interested in
responding to the PHS incentives to transfer in ways that also benefit the BOP.
Specifically, we found that the BOP does not currently use involuntary
transfers of PHS officers to address its staffing needs. BOP officials said that they
initiate involuntary PHS transfers only for disciplinary reasons or for instances in
which an officer needs to be moved to a location where he or she can receive
additional training and oversight. PHS officers we interviewed at BOP institutions
recognized that their status as Commissioned Officers meant that they were
potentially subject to a change of duty station, but they also told us that such
transfers were not actually used. Instead, both PHS officers and civil service
employees control their own duty stations in the same way: by deciding whether to
apply to an advertised vacancy at a particular institution.55 The BOP’s Personnel
Director told us, “they know where the vacancies are so if they wanted to apply to
there, they easily could.” Once hired, PHS officers may also stay in a position for
as long as they like, assuming satisfactory performance, just like civil service
employees.
We also found that the BOP has not been proactive about using PHS officers
to fill vacancies where individual institutions are struggling with particularly
challenging medical personnel staffing needs. Institution staff further told us that
lengthy vacancies are common. For example, staff at one institution told us that
their Clinical Director position has gone unfilled for 15 years.56 A PHS nurse at
54

The PHS recommends that officers have at least three different geographic or
programmatic assignments during their careers, but it does not have a specific requirement for the
frequency of moves. The BOP’s PHS Liaison recommends that officers seeking promotion move every
3 to 5 years and told us that the PHS revised its application process in 2013 to require officers to be
more mobile.
55

The BOP and the union have an informal agreement that all initial vacancies will be
advertised, with both civil service employees and PHS officers eligible to apply. The former Assistant
Director for Health Services and Medical Director said that the BOP made this agreement because it
would be unfair to make any vacancy open only to PHS officers.
56
The Clinical Director is the lead physician in an institution’s health services unit and is
responsible for all clinical care provided at the institution. The Health Services Administrator at this
(Cont’d.)

21


another institution told us that her position had been vacant for approximately
2 years by the time she was hired and that at the time of our interview her
institution had been without a Clinical Director for nearly a year. The BOP Union
President told us that a physician position at a third institution remained vacant for
5 years, which pushed more responsibility onto the mid-level providers who
remained on the staff. He questioned why the BOP allowed that position to remain
unfilled instead of transferring a PHS physician from another location.
More Effective Use of PHS Location Assignments Could Take Multiple Forms
Multiple BOP and PHS officials told us that the BOP could do more with
voluntary and involuntary transfer authorities to better align PHS officers’ duty
stations with the BOP’s greatest needs. In this section, we outline three options
that the BOP could consider to use PHS officers as a means of addressing some of
its most challenging medical staffing problems.
Involuntary Transfers
The use of involuntary transfers for all PHS officers would mirror the
military’s requirement of frequent transfers and reassignments, a process known as
“force management.” BOP officials acknowledge that PHS policies give them the
authority to implement force management if they choose to do so, but they told us
that this would require at least three changes in how BOP institutions are managed:
1. reducing the level of control that Wardens currently have over the selection
of employees to fill institution vacancies,
2. matching all PHS officers with positions available, and
3. reducing the control PHS officers currently have over their duty station.
Effectively using involuntary transfers would also require changes in how the BOP
as a whole is managed, because the BOP would also need to assess which
vacancies are of such high priority that they should be staffed by a transferring PHS
officer rather than remaining vacant. BOP officials told us that they had not
implemented involuntary transfers because they were concerned that such a
change could reduce employee engagement and increase medical staffing
vacancies. The PHS Deputy Director, DCCPR acknowledged these concerns,
recommending that agencies minimize the risk of disengagement by transferring
officers for defined periods of time and by giving the officers some say in the

institution told us that, in the absence of a Clinical Director, they had a contract physician who visited
the institution twice a week, as well as three additional contract physicians who each visited the
institution once a month; the Clinical Director of a different institution participated via phone in
decisions concerning whether an inmate should be referred for medical care outside the institution.
We note, however, that the Clinical Director providing this assistance works at an institution that is
750 miles away from the institution we interviewed, and in a different time zone. Therefore, the lack
of a Clinical Director means that onsite physician care for the 1,268 inmates at this institution is
limited.

22


location of their subsequent transfer.57 Regarding the BOP’s concern that
involuntary transfers would cause PHS officers to leave the BOP for other agencies,
he said that while the PHS encourages its officers to be mobile, it also requires a
minimum 2-year commitment at each duty station and therefore will not process
transfer requests for a PHS officer more frequently.
Targeted Force Management
BOP officials and institution staff suggested to us that the BOP could take
better advantage of the PHS requirement for officer mobility by using force
management in a targeted, rather than broad manner. Some institution staff
suggested that the BOP require PHS officers to spend their first few years with the
BOP working in institutions that have the greatest difficulty filling vacancies. A PHS
Health Assistant Specialist told us that if someone was “hungry” enough for a PHS
commission, he or she would go anywhere to take a position. An institution’s
Human Resource Manager said that this would be preferable to transferring PHS
officers who were already employed in the BOP, which would create a vacancy at
the PHS officer’s previous institution. While the BOP told us that it tries to use its
limited number of PHS waivers in this manner, we believe it could achieve more
effective results if it also used this approach with all PHS officers who are new to
the BOP. In FY 2014, 17 BOP civil service employees converted to the PHS using
waivers, but the BOP gained an additional 61 PHS officers in other ways.58
We also found that the BOP has a precedent of using targeted force
management for some entry-level PHS officers. Students entering their final year
of school or professional training are eligible to apply to the PHS Senior
Commissioned Officer Student Training and Extern Program (Senior COSTEP).
Those accepted by the PHS are sponsored by an agency such as the BOP, paid at
the entry-level ensign rank while completing their education, and agree to work for
their sponsoring agency as a PHS Commissioned Officer immediately following
graduation.59
57
BOP officials said that it would be easier for the military to give officers a voice in the
location of a subsequent transfer because all military personnel face transfer, making it easier to
predict when particular positions and locations will have vacancies. This would be more difficult in the
BOP because medical positions can be also be filled by civil service employees, who cannot be
transferred as easily as PHS officers can.
58

The BOP reported that in FY 2014, 15 civil service employees who already worked for the
BOP converted to the PHS during regular application windows, 21 newly-commissioned PHS officers
joined the BOP, and 25 experienced PHS officers joined the BOP from other agencies.
59
Ensign is the most junior officer rank in the PHS. The required PHS service commitment is
twice the length of time the Senior COSTEP officer received financial support while in school. For
example, the BOP’s COSTEP program statement requires Senior COSTEP officers to serve a minimum
of 8 months in training, followed by a minimum 16-month commitment to the BOP. In 2015, the BOP
and the National Institutes of Health were the only agencies who sponsored Senior COSTEP officers.

These officers are referred to as Senior COSTEP officers despite being entry-level because the
PHS also has a Junior COSTEP program. Junior COSTEP officers have more than 1 year left of their
schooling and may temporarily work for the BOP, or other agencies that employ PHS officers, during
semester breaks.

23


The BOP’s COSTEP Program Statement specifies that assignments for entrylevel officers participating in the Senior COSTEP program are based on the BOP’s
needs.60 A PHS officer working at the BOP’s Central Office serves in the role of
COSTEP Coordinator and is responsible for assessing the BOP’s needs for Senior
COSTEP officers and for assigning them to institutions.61 Institutions request to
participate in the Senior COSTEP program with the knowledge that this would result
in the assignment of an entry-level PHS officer to their institution rather than the
selection of a local candidate after advertising a vacancy. The COSTEP Coordinator
considers the types of vacancies institutions are seeking to fill, whether the
institutions asking to participate in the Senior COSTEP program are a good fit for an
entry-level medical professional, and the location preferences of the Senior COSTEP
officers.62 However, the BOP’s former Assistant Director for Health Services and
Medical Director said that because the BOP’s goal with the Senior COSTEP program
is to maximize the retention of these officers beyond their initial service
commitment, the location preferences of the Senior COSTEP officers and the
availability of mentors are often more important than institution needs when
determining where the Senior COSTEP officers should be assigned.
If the BOP gave greater priority to institution needs, and broadened its
assessment to include positions that should be filled by a more experienced clinician
as well as entry-level positions, then its approach to staffing Senior COSTEP officers
could be expanded to maximize the efficiency of PHS officer placements more
broadly. Such an expansion could accommodate either a decision to implement
force management broadly for all PHS officers or more narrowly for only those PHS
officers who are new to the BOP.63 However, in order for these assessments to be
successful, the BOP would first have to be more strategic about analyzing and
prioritizing its overall recruitment needs.64
BOP Needs Aligned with PHS Promotion Incentives
The BOP could also consider better aligning its needs with the PHS’s
promotion incentives, particularly the PHS’s recent emphasis on mobility. One
long-time PHS officer told us that at the time he was commissioned, the PHS
promoted as a perk the fact that its officers would not be subjected to involuntary
60

BOP, Program Statement 6021.04, Commissioned Officer Student Training Extern Program
(COSTEP) (August 1, 2003), paragraphs 16, 17.
61

In a given year, no more than 30 Senior COSTEP officers are assessed for placement in
BOP institutions.
62

The BOP PHS Liaison told us that because Senior COSTEP officers are entry level, it would
not be appropriate to assign them to an institution where they would have to work independently or
be the senior clinician.
63
PHS officers who are new to the BOP do not necessarily have to be entry level. For
example, civil service employees who convert to the PHS after they start work at the BOP already
have some clinical experience.
64

In response to a working draft of this report, BOP officials noted that when making
decisions concerning the effective management of PHS officers, they must consider the human
resource implications when developing an approach to better utilizing PHS officers.

24


transfers. However, the BOP’s PHS Liaison told us that in 2013 the PHS revised its
application process to require mobility and now screens out applicants who are not
willing to move. As a result of these changes, mobility has become a more
important benchmark in the PHS promotion process.65
The BOP Union President told us that the BOP historically has not required
PHS officers to move and has instead accommodated PHS officers who are
promoted in rank by giving them additional responsibilities at their current
institutions. He suggested that the BOP’s use of PHS officers would be more
effective if PHS officers who needed to take on additional responsibilities due to a
promotion were moved to a position in a different institution. We believe that by
encouraging such transfers, the BOP could better staff the locations where need is
greatest, while also helping the transferred PHS officer demonstrate continued
mobility in his or her next application for a promotion.
Like mobility, receipt of PHS awards is another factor that the PHS promotion
board considers when making promotion decisions. One such award is the PHS’s
isolated hardship award given to PHS officers who serve at least 180 consecutive
days in an area designated as isolated, remote, insular, or constituting a hardship
duty assignment. The BOP has already sought to incentivize PHS officers’ transfers
by having successfully petitioned the PHS to designate five BOP institutions as
“isolated hardship locations” eligible for the award.66 The BOP’s PHS Liaison told us
that a request for a sixth isolated hardship designation for the newly activating
Administrative U.S. Penitentiary, Thomson, Illinois, is pending. We believe the BOP
should consider requesting additional isolated hardship designations in the future,
although we note that according to the BOP’s PHS Liaison, the PHS is in the process
of revising its criteria for awarding the designation.

65
PHS officer promotions in rank are based on the extent to which an officer meets a number
of benchmarks, including performance appraisals, awards, history of assuming roles of increasing
responsibility, continuing education, mobility, willingness to take on collateral duties, integrity,
participation in PHS advisory groups, mentoring, and maintenance of basic readiness standards to
respond to public health emergencies. PHS officers told us that promotions become more competitive
at higher ranks because the higher ranks have fewer positions available. A PHS promotion board, not
the BOP, makes PHS promotion decisions.
66

The five institutions with the designation as of October 2015 are Federal Correctional
Institution (FCI) Safford in Arizona, FCI Manchester in Kentucky, FCI Estill in South Carolina, Federal
Prison Camp Yankton in South Dakota, and FCI Three Rivers in Texas.

25


CONCLUSION AND RECOMMENDATIONS 

Conclusion
In addition to the unavoidable challenges within the BOP’s correctional
setting, the medical staffing challenges the BOP faces stem in part from local
market factors and the limitations of the General Schedule (GS) scale and position
classifications that the BOP cannot adjust without approval from the Office of
Personnel Management (OPM). We found that the BOP has taken a number of
steps to address pay disparities and understaffing challenges, particularly by
increasing its use of incentives and obtaining approval to use an alternate
compensation scale for psychiatrists. However, the approval process for incentives
is laborious, time-consuming, and requires extensive knowledge that not all
institution staffs possess. Further, we found that the continued reliance on shortterm solutions such as temporary duty (TDY) assignments and contracted medical
care has an adverse impact on overall medical costs. We believe that in order to be
more efficient with resources, the BOP must look at other avenues to increase
medical staffing levels.
We also found that the BOP needs to take a more strategic, coordinated, and
agency-wide approach to its recruitment challenges. Such an approach should
begin by improving the BOP’s use of data to identify, prioritize, and address
recruitment challenges and medical staffing needs. For example, the BOP does not
currently prioritize medical staffing vacancies based on the cost of leaving the
vacancies unfilled. These costs can be determined by analyzing the care level of
particular institutions, the extent to which institutions rely on TDY assignments, or
the cost of contracting for care that would be provided if the vacancy were filled.
Similarly, the BOP currently collects position-specific data on the use of incentives
but does not analyze it for recruitment purposes. If the BOP were to analyze this
data to identify positions and locations that are heavily reliant on incentives, then it
could use that information to more accurately identify pay disparities, assess how
frequently supplemental pay is required, and compare the cost of applying multiple
incentives for lower graded positions with the cost that the BOP would incur if
medical positions were reclassified to higher grades. We believe this data would
also be valuable in helping the BOP support its position to the Office of Personnel
Management that the reclassification of certain positions on the GS scale is
necessary for effective recruitment.
Because the BOP has not prioritized medical staffing vacancies through a
strategic, national assessment of its needs, it cannot place PHS officers more
efficiently throughout its institutions. PHS policy offers the BOP a great amount of
latitude in determining where to station PHS officers, but the BOP does not
currently take advantage of these flexibilities. The BOP has several options for
managing PHS officer placements on a national level, and we believe it can do so in
ways that could benefit both the BOP and the individual PHS officers’ needs. Better
assessment of priority medical vacancies could also help the BOP better articulate
its requirements to the PHS when it responds to the PHS’s annual request for
information on the amount of PHS officers the BOP needs. We acknowledge that
26


with approximately 6,500 total officers working across 23 federal agencies and the
District of Columbia, the PHS is not a panacea for the BOP to fill all of its staffing
needs. However, a more thorough analysis of staffing needs throughout the BOP,
rooted in a more strategic approach, could help the BOP better describe its
challenges to the PHS and identify where additional staff are most acutely needed.
Recommendations
To ensure the BOP can recruit and retain the medical professionals that are
necessary to provide medical care to the BOP’s inmate population, and to foster a
proactive, coordinated strategy that will allow the BOP to better use its PHS
officers, we recommend that the BOP:
1.	

Develop a plan to use available data to assess and prioritize medical
vacancies based on their impact on BOP operations.

2.	

Develop strategies to better utilize Public Health Service officers to address
the medical vacancies of greatest consequence, including the use of
incentives, assignment flexibilities, and temporary duty.

27


APPENDIX 1 


EXPANDED METHODOLOGY
Data Analysis
Public Health Service and Civil Service Salary Comparison
We attempted to compare the uniformed service pay scale with the General
Schedule, but we determined that we could not accurately compare the salaries
because some of the factors that influence Public Health Service (PHS) officer
salaries do not have an equivalent in civil service salaries, resulting in great
variance.67 A 2013 University of Maryland study of the PHS found that the costs
associated with the PHS could not be easily quantified for comparison to the civil
service.68 Further, the PHS Deputy Director of the Division of Commissioned Corps
Personnel and Readiness (PHS Deputy Director, DCCPR) confirmed that because of
the variance, the pay scales are too dissimilar to compare.
Bureau of Labor Statistics Salary Analysis
We used publicly available data from the Office of Personnel Management
(OPM) and the Bureau of Labor Statistics (BLS) to analyze the differences in
salaries between medical professionals working at the BOP and the overall salary
averages of medical professionals in a given geographic location.69 We based our
selection of geographic locations on counties that were in close proximity to BOP
institutions. We then used the county of the institution to select the applicable
region for BLS data and the applicable locality for OPM data. When analyzing OPM
data, we used the highest available grade, but the lowest step for the given position
according to OPM’s position classification standards. For example, dentists in the
BOP can be either grade 11 or grade 12, so we used the salary of grade 12, step 1
for our analysis. We believe this allowed for a reasonable comparison with the BLS
averages because it represented a salary in the middle of the allowable range for
that position. In a separate analysis, we examined special pay tables that OPM had
established for dentists and pharmacists in some BOP institutions, but we concluded
that special pay was not sufficient to address the wage gap we found when
comparing locality pay tables with BLS data.

67

Specifically, pay for PHS officers varies based on geographic location, base pay, years of
service, dependents, specialty, allowance for subsistence, and rank. The PHS Deputy Director, DCCPR
noted that some portions of PHS officer pay are also tax-exempt.
68

According to the University of Maryland, the effectiveness, efficiency, efficacy, and
comprehensive value of the PHS cannot be determined based on cost factors alone because there
exist too many variables, inconsistencies, and un-measurable attributes to make a meaningful
evaluation. Muhiuddin Haider, The USPHS Commissioned Corps: A Study on Value and Contributions
to DHHS Mission and National and Global Health Priorities and Initiatives (University of Maryland,
2013).
69

BOP salary averages are included in the data captured by the Bureau of Labor Statistics.

28


Incentives Awarded by Position
The BOP provided data on recruitment and retention incentives awarded from
FY 2010 to 2014. We used this data to total the number of incentives awarded, and
the cost associated with those of monetary value. Our analysis of monetary
incentives compared the incentives by type and position and used position counts
to calculate averages. In determining position counts, we accounted for those
individuals who received more than one incentive.
Interviews
We interviewed Central Office officials, including the Assistant Directors of
the Human Resource Management and Health Services Divisions; the BOP’s
Personnel Director; the BOP PHS Liaison; the Chief of Budget Execution; and the
Chief of Health Services Staffing and Recruitment.
We visited five institutions via video teleconference and, during those visits,
we interviewed institution senior management, as well as staff who provide direct
clinical care to inmates. We interviewed four Wardens, one Associate Warden, five
Health Services Administrators, five Business Administrators, five Human Resource
Managers, a Leave Maintenance Clerk, and BOP and PHS clinical staff, including:
an occupational therapist, a health systems specialist, four non-supervisory
registered nurses, a physician assistant, a nurse practitioner, and two pharmacists.
At PHS Headquarters, we interviewed an official in the DCCPR.
Site Visits
The team conducted video teleconferences with the five following institutions,
representing all four healthcare levels: Federal Medical Center Butner, Federal
Correctional Institution (FCI) Danbury, Federal Medical Center Rochester, FCI
Sandstone, and Federal Detention Center SeaTac. We selected these five
institutions because they had a combination of a high number or high percentage of
PHS staff in FY 2014. We were also able to use these locations to assess hiring
challenges across medical, detention, and standalone institutions, in both rural and
metropolitan locations.
Additional Objectives
At the outset of this review, we included a report objective examining the
BOP’s oversight of PHS officer leave, awards, drug testing, and correctional
training. We reviewed BOP and PHS policies related to these topics and asked
questions on these topics during Central Office interviews and site visits described
above. However, during these interviews we learned about larger concerns that
BOP staff had regarding medical staffing in general. We met with officials from the
BOP’s Program Review Division and Health Services Division in September 2015 to
formally close the original objective. At that meeting, we also added a review

29


objective examining the challenges and limitations the BOP faces in hiring medical
professionals to work in its institutions.70 The BOP officials we met with in
September 2015 said that recruitment and retention of quality medical
professionals is the BOP’s biggest challenge.

70

We conducted some of our Central Office interviews after this meeting to discuss the topics
raised in our new objective.

30


APPENDIX 2 

THE BOP’S RESPONSE TO THE DRAFT REPORT 


..
I)

U.S. Department of JUJItice

,

Federal Bureau of Pnsons

,-;;:

March 15 ,

2016

MEMORANDUM FOR NINA S. PELLETIER

ASSISTANT INSPECTOR GENERAL
OFFICE OF INSPECTOR GENERAL
EVALUATION AND INSPECTIONS DIVISION

FROM:

Thomas R. Kane, Acting Director

SUBJECT:

Response to the Office of Inspector General's (DIG)
DRAFT Report:
orG Review of the Impact of the
Federal Bureau of PriBona' Medical Staffing
Challenges, Assignment Number A 2015 005

The Bureau of prisons (BOP) appreciates the opportunity to respond
to the open recommendations from the draft report entitled orG Review
of the Impact of the Federal Bureau of Prisons' Medical Staffing
Challenges.

Therefore, please find the Bureau'!! response to the recommendations
below:
Reco!llllendationa

To ensure the BOP can continue to recruit and retain the ~~dical
professionals that are necessary to provide medical care to its
inmate population, and to foster a proactive, coordinated strategy

31


that wi l l allow the BOP to better use its PHS officers, we recommend
that the BOP,
Recommenda t i on 1:
"Deve l op a plan to use available data to assess
and prioritize medical vacancies based on their impact on BOP
operations."
Re sponse : The BOP agrees with this recommendation and will explore
options to better assess and provide targeted strategies for medical
vacancies , resulting in an identified plan that will be provided to
the OIG.
Recomme ndati o n 2:
" Develop strategies to betcer utilize Public
Health Service officers to address the medica l vacancies of greatest
consequence, including the use of incentives, assignment
flexibilities, and temporary duty."
Re s ponse:
The BOP believes the history and complexity of the
relationship between the civil service and public Health Service
(PHS) personnel systems is not adequately detailed in the OIG report,
and has a significant impact on BOP's management of those staff .
Nevertheless, the BOP agrees with this recommendation, and wi l l
explore and develop strategies to better utilize PHS officers to
address the medical vacancies of greatest consequence.
As discussed
during the exit conference for this review, BOP will explore the
OIG's p r oposed solutions in its report t as well as other options that
may appropriately address the situation.
If you have any questions regarding this response, please contact
Steve Mora, Assistant Director , Program Review Division, at
(202)

353-2302.

2

32


APPENDIX 3 

OIG ANALYSIS OF THE BOP’S RESPONSE
The Office of the Inspector General (OIG) provided a draft of this report to
the Federal Bureau of Prisons (BOP) for comment. The BOP’s response is in
Appendix 2. Below, we discuss the OIG’s analysis of the BOP’s response and
actions necessary to close the recommendations.
Recommendation 1: Develop a plan to use available data to assess and
prioritize medical vacancies based on their impact on BOP operations.
Status: Resolved.
BOP Response: The BOP concurred with the recommendation and stated
that it would develop a plan by assessing medical vacancies and develop more
targeted strategies to fill them.
OIG Analysis: The BOP’s planned actions are responsive to our request. By
June 30, 2016, please provide the BOP’s plan illustrating the strategies developed
to fill medical vacancies. As part of the plan, please explain how the BOP will
prioritize medical vacancies based on the length of vacancies, patterns in
institutions’ use of incentives, patterns in institutions’ use of temporary duty, the
cost of outside medical care, and any other sources of data that the BOP believes
demonstrate the impact of leaving the positions vacant. Additionally, please
describe how frequently the BOP plans to reassess medical vacancies and
reconsider their prioritization.
Recommendation 2: Develop strategies to better utilize Public Health
Service officers to address the medical vacancies of greatest consequence,
including the use of incentives, assignment flexibilities, and temporary duty.
Status: Resolved.
BOP Response: The BOP concurred with the recommendation and stated
that it would explore and develop strategies to better utilize PHS officers to address
the medical vacancies of greatest consequence. The BOP further stated that it
would explore the options outlined in this report, as well as other options that may
appropriately address the situation.
OIG Analysis: The BOP’s planned actions are responsive to our request. By
June 30, 2016, please describe how the BOP plans to better use PHS officer
incentives, assignment flexibilities, and temporary duty to fill the highest priority
medical vacancies identified through the strategy developed in response to
Recommendation 1. As part of this response, please describe how the BOP
considered the options discussed in the report.

33


 
 
 

 

 
 
 
 
 
 
 
 
 
 
 
 
 

The Department of Justice Office of the Inspector General
(DOJ OIG) is a statutorily created independent entity
whose mission is to detect and deter waste, fraud,
abuse, and misconduct in the Department of Justice, and
to promote economy and efficiency in the Department’s
operations. Information may be reported to the DOJ
OIG’s hotline at www.justice.gov/oig/hotline or
(800) 869-4499.

 
 

 

Office of the Inspector General
U.S. Department of Justice
www.justice.gov/oig