HEALTHCARE IN THE FEDERAL PRISON SYSTEM

By Alan Ellis

There are four CARE Levels in the Bureau of Prisons (BOP) medical CARE Level classification system. A provisional care level is assigned by the Designation and Sentence Computation Center (DSCC), based primarily on information contained in the Presentence Investigation Report. After arrival at the designated facility, the provisional care level is reviewed and a non-provisional CARE Level is assigned by BOP clinicians. These assignments depend on the clinical resources an inmate needs and his or her ability to function daily without assistance. Some diagnostic categories such as cancer, diabetes, HIV, hepatitis may also be used to determine an inmate’s care level.

CARE Level 1 Inmates:

• Inmates are generally healthy, but may have limited medical needs that can be easily managed by clinician evaluations every six months; and
• Inmates are less than 70 years of age.
• CARE Level 1 designations are made by the DSCC.
• Examples: mild asthma, diet-controlled diabetes, stable HIV patients not requiring medications.

CARE Level 2 Inmates:

• Inmates are stable outpatients who require at least quarterly clinician evaluations.
• Can be managed through routine, regularly scheduled appointments with clinicians for monitoring, including for mental health issues.
• Enhanced medical resources, such as consultation or evaluation by medical specialists, may be required from time to time, but are not regularly necessary.
• CARE Level 2 designations are made by the DSCC.
• Examples: medication-controlled diabetes, epilepsy, or emphysema.

CARE Level 3 Inmates:

• Inmates are fragile outpatients who require frequent clinical contacts to prevent hospitalization for catastrophic events.
• May require some assistance with activities of daily living, such as bathing, dressing, or eating, but do not need daily nursing care.
• Other inmates may be assigned as "companions" to provide the needed assistance.
• Stabilization of medical or mental health conditions may require periodic hospitalization.
• Examples: cancer in remission less than a year, advanced HIV disease, severe mental illness in remission on medication, severe congestive heart failure, end-stage liver disease.
• Designation of CARE Level 3 inmates is made by the BOP’s Office of Medical Designation and Transportation in Washington, D.C.
• BOP Care Level III Facilities include:
  • FCI Terminal Island, California
  • FCI Ft. Worth, Texas
  • FCC Terre Haute, Indiana
  • FCC Butner, North Carolina

CARE Level 4 Inmates:

• Inmates require service available only at a BOP Medical Referral Center (MRC) which provides significantly enhanced medical services and limited in-patient care.
• May need daily nursing care.
• Functioning may be severely impaired and requires 24-hour skilled nursing care or nursing assistance.
• Examples: cancer on active treatment, dialysis, quadriplegia, stroke or head injury patients, major surgical treatment, high-risk pregnancy.
• Designation of CARE Level 4 inmates is made by the BOP’s Office of Medical Designation and Transportation in Washington, D.C.
• The BOP operates six care level 4 MRCs:
  • U.S. Medical Center for Federal Prisoners, Springfield, Missouri provides care primarily for higher security level inmates, and includes a full dialysis unit as well as an inpatient mental health unit.
  • FMC Rochester, Minnesota is affiliated with the Mayo Clinic for complex medical requirements, and includes an inpatient mental health unit.
  • FMC Lexington, Kentucky generally manages lower security level inmates.
  • FMC Devens, Massachusetts includes a dialysis unit and an inpatient mental health unit, as well as the residential Sex Offender Treatment Program.
  • FMC Butner, North Carolina includes an inpatient mental health unit, and can manage inmates at all security levels. It is the cancer treatment center for the BOP.
  • FMC Carswell, Texas is exclusively for female inmates and is the only FMC available for women. It includes an inpatient mental health unit.

The BOP defines its scope of medical services according to five levels of medical intervention:

Medically Necessary - Acute or Emergent. Medical conditions that are of an immediate, acute or emergent nature, which without care would cause rapid deterioration of the inmate’s health, significant irreversible loss of function, or may be life-threatening.

Medically Necessary - Non-Emergent. Medical conditions that are not immediately life-threatening but which without care the inmate could not be maintained without significant risk of:

• serious deterioration leading to premature death;
• significant reduction of the possibility of repair later without present treatment; or
• significant pain or discomfort which impairs the inmate’s participation in activities of daily living.

Medically Acceptable - Not always Necessary.Treatment is considered elective when it may improve the inmate’s quality of life. Relevant examples in this category include, but are not limited to:

• joint replacement;
• reconstruction of the anterior cruciate ligament of the knee; and
• treatment of non-cancerous skin conditions (e.g. skin tags, lipomas).

Limited Medical Value. Medical conditions for which treatment provides little or no medical value, are not likely to provide substantial long-term gain, or are expressly for the inmate’s convenience. Procedures in this category are usually excluded from the scope of services provided to Bureau inmates. Examples in this category include, but are not limited to:

• minor conditions that are self-limiting;
• cosmetic procedures (e.g. blepharoplasty [cosmetic surgery on the eyelids]); or
• removal of non-cancerous skin lesions.

Extraordinary.Medical interventions are deemed extraordinary if they affect the life of another individual, such as organ transplantation, or if they are investigational in nature.

It is the policy of the BOP to provide care that its clinicians determine to be medically necessary. Those medical interventions that fall into the categories of "medically necessary, acute or emergent" or "medically necessary, non-emergent" are those the agency considers to be medically necessary. Those that fall into the classification of "medically appropriate but not always necessary" are considered elective and must undergo review by a Utilization Review Committee before approval. They are unlikely to be approved because of the BOP’s limited medical resources. In addition, pretrial or non-sentenced inmates, and inmates with less than 12 months to serve, are ineligible for health services considered "medically appropriate – not always necessary," "limited medical value," or "extraordinary".

Alan Ellis, Past President of NACDL, specializes in sentencing, prison matters, and post conviction remedies with offices in San Francisco, CA and Philadelphia, PA. He is a co-author of the Federal Prison Guidebook and the Federal Sentencing Guidebook and a contributing editor to Criminal Justice magazine for whom he writes a quarterly column on federal sentencing. Mr. Ellis has been described as "one of this country’s pre-eminent criminal defense lawyers" by Federal Lawyer magazine. The United States Court of Appeals for the Ninth Circuit in a published decision has identified him as a "nationally recognized expert in federal criminal sentencing."