Immigration Detention: Additional Actions Needed to Strengthen Management and Oversight of Detainee Medical Care
Highlights
What GAO Found
The Department of Homeland Security's (DHS) U.S. Immigration and Customs Enforcement (ICE) oversees basic on-site medical care at all facilities, as required by ICE detention standards, but does not maintain complete information about medical care costs. The ICE Health Service Corps (IHSC) provided direct care to detainees at 19 over-72-hour facilities and oversaw care at the remaining 146 non-IHSC-staffed facilities in fiscal year 2015. At all facilities, IHSC uses an electronic system, the Medical Payment Authorization (MedPAR) system, to approve or deny off-site care requests for detainees; such requests could include dental visits or surgical needs. IHSC uses a system different from MedPAR to track costs or amounts paid for off-site care. The use of separate systems limits ICE's ability to link approvals and payments. For example, the number of claims paid for fiscal years 2012 through 2014 did not correspond to the number of IHSC MedPAR approvals for requested services for the same time period. While there are valid reasons for these differences, such as that approvals and claims could be made in different fiscal years, establishing a mechanism to more fully ensure that payments for off-site care are supported by the appropriate authorizations could help ICE monitor medical care costs and better validate payments.
ICE conducts medical care compliance inspections at individual facilities, but conducts limited analyses of inspection data across facilities and over time. ICE uses seven oversight mechanisms to monitor facilities' compliance with medical care detention standards, such as facility inspections and on-site detention monitors. The combined use of these oversight mechanisms resulted in more than 99 percent of ICE's average daily population (ADP) of approximately 28,000 detainees being covered by two or more mechanisms in fiscal year 2015. ICE's priority has been to focus on local, facility-specific issues rather than perform overarching analyses. For example, ICE does not utilize the data gathered through these mechanisms in a way that examines overall trends in medical care deficiencies. Conducting analysis of oversight data over time, by detention standards, and across facilities, consistent with internal control standards, could strengthen ICE's ability to manage and oversee the provision of medical care across facility types.
DHS has various processes to obtain and address the hundreds of medical care complaints it receives annually. Specifically, detainees can submit complaints regarding medical care directly to facilities or to one of various DHS entities, including the Office of Inspector General and Office for Civil Rights and Civil Liberties. These entities generally determine whether to take their own action on the complaints or forward them to ICE for resolution. These entities maintain complaint data in various ways, and IHSC, which is ultimately responsible for addressing medical complaints received, is developing and piloting a new system for managing tasks, including addressing complaints. However, internal control standards call for evaluation of performance over time, and it is unclear whether IHSC's new system will capture all medical complaints received by DHS or facilitate analyses of complaints over time and across facilities. Ensuring that a new tasking system would capture all complaints and facilitate analysis could improve DHS's decision-making for detainee medical care.
Why GAO Did This Study
DHS is responsible for providing safe, secure, and humane confinement for detained aliens who may be subject to removal or have been ordered removed from the United States. GAO was asked to examine the provision and oversight of medical care in immigration detention facilities. This report examines the extent to which DHS (1) has processes for administering detainee medical care and maintaining cost information for care, (2) monitors and assesses compliance with medical care standards, and (3) oversees processes to obtain and address complaints about detainee medical care.
GAO reviewed ICE data and information on costs, detention population, standards, and oversight for 165 facilities that held detainees for more than 72 hours in fiscal year 2015. GAO also reviewed complaint processes, interviewed DHS and ICE officials, and visited 12 facilities selected based on detainee population and facility type, among other factors. The visit results are not generalizable, but provided insight to the provision of medical care.
Recommendations
GAO recommends that DHS, among other things, ensure payments for medical care are supported by authorizations, conduct trend analyses of oversight data, and track all medical complaints received by DHS entities. DHS concurred with the recommendations and identified planned actions to address the recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Homeland Security | To enhance Department of Homeland Security's (DHS) U.S. Immigration and Customs Enforcement's (ICE) ability to make more effective business decisions across immigration detention facilities with respect to the provision of medical care, the Secretary of Homeland Security should direct ICE to develop and implement a mechanism to identify and assess trends in off-site medical care procedures across types of procedures and facilities. |
In February 2016, we reported that ICE's system for managing the provision of off-site medical care did not provide ICE with the information needed to identify and assess trends across the types of off-site care requested or approved over time or across facility types. In April 2017, ICE officials reported that in repose to this recommendation, ICE Health Service Corps (IHSC) collaborated with Veterans Affairs Financial Services Center (VAFSC) and Deloitte Consulting to develop an Off-site Medical Procedures Dashboard and Analytics Tool that visualizes trends and allows staff to analyze information across multiple datasets. According to officials, the tool is integrated with program activities to improve assessment and analysis of external medical referrals. In addition, the referral data were combined with ICE's custody information to determine, for example, which facilities refer detainees more often based on the amount of detainees that pass through a facility in a given time period. This will allow ICE to compare facilities to one another independent of their size. Officials also noted that IHSC is in the process of combining Electronic Health Records and VAFSC claims data to help identify any duplication of services provided, and that the dashboard highlights medical claims that appear abnormal. ICE provided us with the February 2017 Veterans Affairs Claims Dashboard User Guide, and officials stated that IHSC will conduct training for designated users beginning in April 2017. Implementing this dashboard and analytics tool should help ICE identify and assess trends in off-site medical care, and potentially improve operations and/or resource allocations.
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| Department of Homeland Security | To enhance Department of Homeland Security's (DHS) U.S. Immigration and Customs Enforcement's (ICE) ability to make more effective business decisions across immigration detention facilities with respect to the provision of medical care, the Secretary of Homeland Security should direct ICE to develop and implement a mechanism to ensure that payments for off-site care are supported by the appropriate authorizations. |
In February 2016, we reported that ICE Health Service Corps (IHSC) utilized multiple data systems to administer the provision of off-site medical care to detainees. More specifically, IHSC used the Medical Payment Authorization Request (MedPAR) system to approve or deny off-site care requests for detainees, while payments to outside providers were managed by the Veterans Affairs Financial Services Center (VAFSC). The use of separate systems limited ICE's ability to link approvals and payments. In December 2016, IHSC and VAFSC approved the ICE Health Service Corps Medical Claims Processing Business Requirements Document. The document details approximately 90 business rules across 15 categories, such as Claim Submission, Claims Processing, System Configuration, Reporting, and Data. Under the Claims Processing category, several rules govern processes to help ensure that payments for detainee off-site medical care are supported by the proper authorizations. In addition, a fiscal year 2017 interagency agreement between IHSC and VAFSC contains other medical claims processing requirements. For example, among other things, the agreement requires VAFSC to meet certain performance measures related to processing claims accurately and avoiding duplicate payments. The agreement also stipulates that VAFSC will conduct an annual independent audit to help ensure that its internal control structures are adequate. Implementing these actions should assist ICE in administering off-site medical care to detainees, and provide greater assurance that payments are authorized appropriately.
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| Department of Homeland Security | To enhance Department of Homeland Security's (DHS) U.S. Immigration and Customs Enforcement's (ICE) ability to make more effective business decisions across immigration detention facilities with respect to the provision of medical care, the Secretary of Homeland Security should direct ICE to track inspection results and conduct analyses of oversight data over time, by standards, and by facility type. |
In February 2016, we reported that ICE conducted medical care compliance inspections at individual facilities--covering more than 99 percent of ICE's average daily population of detainees--but that ICE could take additional steps to track and analyze inspection data across facilities and over time. In November 2017, ICE reported that it had taken actions to improve data collection, which enhanced ICE's ability to analyze inspection data across facilities, over time, and by different medical detention standards. For example, before 2017, facility site visit reports were completed in fillable PDF forms or in Microsoft Word documents, which made it difficult to analyze batches of files for trends without an undue burden of effort, according to ICE. More recently, ICE developed SharePoint applications to receive various inspection and compliance data, and these new applications allow for more robust trend analysis and reporting, along with the tracking and management of any facility corrective action plans. Furthermore, at the end of fiscal year 2017, ICE established ad-hoc and routine reporting parameters that utilize the aggregate inspection data contained in the new SharePoint applications. Implementing improved data collection processes and establishing procedures to analyze the data should help ICE make more effective business decisions regarding medical care across its detention facilities.
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| Department of Homeland Security | The Secretary of Homeland Security should ensure that IHSC's planned new tasking system includes all medical-care-related complaints received by DHS entities, and that this system facilitates the tracking and analysis of complaints over time and across facilities. |
In February 2016, we reported that the ICE Health Service Corps (IHSC) employs a tasking system to document receipt of medical care related complaints obtained from other entities and the tasking of those complaints to IHSC personnel for review and resolution. However, we noted that opportunities existed for IHSC to maintain and utilize more comprehensive data on medical complaints. In February 2017, ICE officials reported that the IHSC Task Management System was fully deployed in 2016 and provided us with a March 2016 System Guide. Among other things, the guide explains concepts, assigns responsibilities, and details procedures for receiving, initiating, and responding to tasks. According to officials, with the data collected to date, the application has allowed IHSC to aggregate and analyze data and trend medical related complaint data. In addition, IHSC is now able to produce reports and statistics on a quarterly, annual and ad-hoc basis. Implementing a more robust task management system should allow ICE to better track and analyze medical complaints, and potentially improve operations.
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