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    Results:

    Subject Term: "Health care"

    127 publications with a total of 416 open recommendations including 40 priority recommendations
    Director: Seto Bagdoyan
    Phone: (202) 512-6722

    3 open recommendations
    Recommendation: The Administrator of CMS should provide fraud-awareness training relevant to risks facing CMS programs and require new hires to undergo such training and all employees to undergo training on a recurring basis. (Recommendation 1)

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Administrator of CMS should conduct fraud risk assessments for Medicare and Medicaid to include respective fraud risk profiles and plans for regularly updating the assessments and profiles. (Recommendation 2)

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Administrator of CMS should, using the results of the fraud risk assessments for Medicare and Medicaid, create, document, implement, and communicate an antifraud strategy that is aligned with and responsive to regularly assessed fraud risks. This strategy should include an approach for monitoring and evaluation. (Recommendation 3)

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Katherine M. Iritani
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: The Secretary of HHS should expeditiously develop a plan--that includes priorities, timeframes, clear roles and responsibilities, and methods for assessing progress--to effectively implement the NAS-related recommendations identified in the Protecting Our Infants Act: Final Strategy. (Recommendation 1)

    Agency: Department of Health and Human Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To help ensure that the WTC Health Program quality assurance (QA) program addresses required QA elements, including the three elements mandated in the Zadroga Act, the Director of NIOSH should develop and implement procedures for conducting systematic reviews of each clinic's QA plan (recommendation 1).

    Agency: Department of Health and Human Services: Public Health Service: Centers for Disease Control and Prevention: National Institute for Occupational Safety and Health
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help ensure that the WTC Health Program QA program addresses required QA elements, including the three elements mandated in the Zadroga Act, the Director of NIOSH should develop and disseminate guidance that clearly specifies how the clinics should address mandated elements in their QA plans (recommendation 2).

    Agency: Department of Health and Human Services: Public Health Service: Centers for Disease Control and Prevention: National Institute for Occupational Safety and Health
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help ensure that the WTC Health Program QA program addresses required QA elements, including the three elements mandated in the Zadroga Act, the Director of NIOSH should develop uniform performance measures that clinics are required to use to consistently evaluate mandated elements through their audits every quarter (recommendation 3).

    Agency: Department of Health and Human Services: Public Health Service: Centers for Disease Control and Prevention: National Institute for Occupational Safety and Health
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Gerald L. Dillingham, Ph.D.
    Phone: (202) 512-2834

    3 open recommendations
    Recommendation: To increase transparency and obtain information to better inform decisions on whether to investigate potentially unfair or deceptive practices in the air ambulance industry, the Secretary of Transportation should take steps, once complaints are collected, to make pertinent aggregated complaint information publicly available for stakeholders, such as the number of complaints received by provider, on a monthly basis.

    Agency: Department of Transportation
    Status: Open

    Comments: When we confirm what actions the Department has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase transparency and obtain information to better inform decisions on whether to investigate potentially unfair or deceptive practices in the air ambulance industry, the Secretary of Transportation should assess available federal and industry data and determine what further information could assist in the evaluation of future complaints or concerns regarding unfair or deceptive practices.

    Agency: Department of Transportation
    Status: Open

    Comments: When we confirm what actions the Department has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase transparency and obtain information to better inform decisions on whether to investigate potentially unfair or deceptive practices in the air ambulance industry, the Secretary of Transportation should consider consumer disclosure requirements for air ambulance providers, which could include information such as established prices charged, business model and entity that establishes prices, and extent of contracting with insurance.

    Agency: Department of Transportation
    Status: Open

    Comments: When we confirm what actions the Department has taken in response to this recommendation, we will provide updated information.
    Director: Beryl H. Davis
    Phone: (202) 512-2623

    15 open recommendations
    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to annually report improper payment estimates and error rates for the advance PTC program.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with this recommendation. HHS stated that in FY 2016, it completed a risk assessment of the advance PTC program and reported results in the FY 2016 Agency Financial Report. Currently, HHS is unable to specify the year the rate and amount will be reported due to the complexity and timing of the error rate measurement methodology process, which involves conducting pilot testing, using those pilots to refine the methodology, and then undergoing the rulemaking process before implementing the methodology to ensure accurate and efficient reporting of an improper payment rate.
    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, and until annual reporting of improper payment estimates and error rates for the advance PTC program is performed, the Secretary of Health and Human Services should direct the Administrator of CMS to disclose significant matters relating to the Improper Payments Information Act (IPIA) estimation, compliance, and reporting objectives for the advance PTC program in the agency financial report, including CMS's progress and timeline for expediting the achievement of those objectives and the basis for any delays in meeting IPIA requirements.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with this recommendation. HHS stated that it reported information on the status of the advance PTC risk assessment in the FY 2014 to FY 2016 Agency Financial Reports. Now that the program's improper payment risk assessment is completed, HHS will continue to report on its progress in designing and implementing an improper payment estimate for the advance PTC program in future Agency Financial Reports.
    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for verifying the identities of phone and mail applicants to reasonably assure that ineligible individuals are not enrolled in qualified health plans in the marketplaces or provided advance PTC.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS neither agreed nor disagreed with this recommendation. However, regarding verification of filer identity, HHS stated that for individuals starting a new application via phone, the call center representatives use verbal attestations for identity verifications from individuals. HHS stated that for paper applications, individuals must provide names and complete addresses as well as other information. In addition, HHS stated that individuals must attest that the information they provide on all applications is accurate by signing under penalty of perjury. GAO continues to believe that because CMS does not validate the identities of individuals who apply by phone or mail, CMS is vulnerable to enrolling ineligible individuals in qualified health plans with advance PTC.
    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to assess and document the feasibility and availability of obtaining sufficiently reliable data to verify individuals' residencies and lack of minimum essential coverage from nonfederal employers and, if appropriate, design and implement procedures for using such data in its verification processes.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with this recommendation. HHS stated that its previous assessments of available electronic data sources did not identify any comprehensive national data source for verifying residency. HHS recently conducted a study to assess the feasibility of developing an employer-sponsored coverage database and determined that development would be costly and highly burdensome given available resources. Additionally, HHS stated that it would impose extra burden on employers to collect the information needed to build a comprehensive employer-sponsored coverage database. HHS will continue to assess and document whether any sufficiently reliable data sources exist and examine the feasibility of implementation.
    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for sending notices to nonfederal employers routinely and terminating advance PTC for individuals who have access to minimum essential coverage from their employers.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS neither agreed nor disagreed with this recommendation. However, regarding sending notices to nonfederal employers, HHS stated that it is evaluating its 2016 employer notice program to determine the best approach for notifying employers in the future. Such an evaluation may provide useful information; however, GAO continues to believe that designing and implementing procedures for sending notices to nonfederal employers and terminating advance PTC to individuals with access to employer-sponsored coverage can reduce the risk of providing advance PTC to issuers on behalf of ineligible individuals.
    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to assess and document the feasibility of approaches for (1) identifying duplicate government-sponsored coverage for individuals receiving Medicaid and Children's Health Insurance Program coverage in federally facilitated marketplace states outside of the states where they attest to residing and (2) periodically verifying individuals' continued eligibility by working with other government agencies to identify changes in life circumstances that affect advance PTC9 eligibility--such as commencement of duplicate coverage or deaths-- that may occur during the plan year and, if appropriate, design and implement these verification processes.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with this recommendation. HHS stated that its preliminary analysis indicates that identifying government sponsored coverage for individuals receiving Medicaid and CHIP in Federally-facilitated Exchange states outside of the state where the applicant is enrolled in coverage would add several months to the time needed to execute the process of identifying duplicate enrollees and ending their advance PTC. Such additional time would significantly reduce the timeliness and effectiveness of the process and lead to an increase in burden on the state Medicaid systems used to verify duplicate coverage. HHS stated that it will continue this analysis and document the feasibility of approaches for identifying duplicate government sponsored coverage for individuals receiving Medicaid and CHIP coverage in Federally-facilitated Exchange states outside the application state of the consumer as well as periodically verifying individual's continued eligibility. In addition, HHS stated that it has implemented a Periodic Data Matching process to proactively identify consumers who may be receiving Minimum Essential Coverage through Medicare, and thus are no longer eligible for financial assistance to help pay for Exchange coverage. HHS is also exploring approaches to identifying Exchange enrollees who may be deceased and should thus be disenrolled from coverage.
    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to assess and document the feasibility of approaches for terminating advance PTC on a timelier basis and, as appropriate, design and implement procedures for improving the timeliness of terminations.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with this recommendation. HHS stated that it continues to assess the feasibility of terminating advance PTC at various times of the month as a result of consumers not resolving inconsistencies. HHS currently terminates advance PTC between the 1st and 15th of the month following the end of the inconsistency clock in order to accommodate issuer processes. HHS stated that processing in these cohorts also allows for operational and quality efficiencies for HHS since processes can be completed in batches.
    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for verifying compliance with applicable tax filing requirements--including the filing of the federal tax return and the Form 8962, Premium Tax Credit--necessary for individuals to continue to be eligible for advance PTC.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with this recommendation. HHS stated that the IRS provides information to Exchanges on consumers who received advance PTC in the prior coverage year but have not taken the necessary steps to file a tax return and reconcile advance PTC. Beginning in Open Enrollment for 2018, the Federally-facilitated Exchange will end advance PTC on behalf of the tax filers who have not filed or have not reconciled advance PTC when that information is reported to the Exchange by IRS.
    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for verifying major life changes using documentation submitted by applicants enrolling during special enrollment periods.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with this recommendation. HHS stated that it is continually monitoring the operations of the Exchange and has taken several steps to analyze and strengthen current rules and procedures to ensure that only those who are eligible enroll through special enrollment periods. While special enrollment periods provide a criticial pathway to coverage for qualified individuals who experience qualifying events, it's equally important that special enrollment periods are not misused or abused. HHS also stated that in April 2017, it issued a final rule on Market Stabilization that promotes program integrity by requiring individuals to submit supporting documentation for special enrollment periods and ensures that only those who are eligible are able to enroll. It will encourage individuals to stay enrolled in coverage all year, reducing gaps in coverage and resulting in fewer individual mandate penalties and help to lower premiums. This process will begin in June 2017.
    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for verifying with IRS (1) household incomes, when attested income amounts significantly exceed income amounts reported by IRS or other third-party sources, and (2) family sizes.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS neither agreed nor disagreed with this recommendation. However, regarding verification of household income and family sizes, HHS stated that as part of its eligibility verification requirements, it verifies consumer-reported income with data from IRS. However, HHS stated that because household incomes may fluctuate year to year, it is difficult for consumers to project income for the year in advance. According to HHS, in instances where applicant-reported income is higher than the IRS data, HHS accepts the consumer attestation. However, HHS stated that it will assess the feasibility and burden on individuals of setting a reasonable threshold for the generation of annual household income inconsistencies that would require additional verification for consumer-attested income that significantly exceeds income amounts reported by IRS or other third party sources. We believe that such an evaluation is a reasonable step to address our recommendation to enhance the effectiveness and efficiency of the program related to verification of household income. In addition, HHS stated that it currently accepts attestation when the family size provided by the individual does not match IRS's records. HHS stated that establishing a process to verify family size with IRS would require significant operational and privacy complexity. While we recognize that there may be certain complexities in the verification of family sizes, it is important that CMS develop policies and procedures to reasonably assure that such verifications are made on a regular basis.
    Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to assess the program against applicable IPIA-defined thresholds and conclude on its susceptibility to significant improper payments, and revise the scope of its improper payments susceptibility assessment for the PTC program to include instances in which advance PTC is greater than or equal to the amount of PTC claimed on the tax return. If the program meets the IPIA definition for being susceptible to significant improper payments based on this assessment, estimate and report improper payments associated with the PTC program consistent with IPIA requirements.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: The IRS partially agreed with this recommendation. IRS stated that instances in which the advance payment of the PTC is greater than or equal to the amount of the PTC claimed on the tax return do not result in the IRS increasing the outlay related to PTC, and so by definition these occurrences are not subject to IPIA, as amended. The IRS understands and shares the concern about the misreporting of items on tax returns, including cases where the taxpayer misreports excess advance PTC, but the IRS has many compliance programs that operate outside the scope of IPIA and that address taxpayer error and noncompliance. The IRS conducted its fiscal year 2016 PTC improper payment risk assessment consistent with guidance from the Office of Management and Budget (OMB), which concurred with our methodology. However, the IRS is committed to discussing with OMB a future change to the agreed-upon procedures to assessing PTC improper payments as part of our larger and ongoing discussions with OMB about the administration of refundable tax credits and the challenges of reporting those credits through the framework of improper payments legislation and guidance.
    Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to assess and document the feasibility of approaches for incorporating information from the marketplaces on individuals who did not demonstrate that they met the eligibility requirements for citizenship or lawful presence in the tax compliance process. If determined feasible, IRS should work with Treasury to require marketplaces to periodically provide such information on individuals and use such information to recover advance PTC made for those individuals.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: The IRS agreed with this recommendation. IRS stated that it will evaluate the feasibility of receiving information from the marketplaces, and the value of using that information in its processes. If IRS determines that obtaining the data would be feasible and using it would be cost-effective, IRS will consult with Treasury on regulations or other guidance needed to obtain the information. Although eligibility determinations for the advance PTC are made outside the IRS's purview, the IRS has taken steps to ensure that the PTC is administered fairly and properly. For example, IRS has updated guidance in Publication 974, Premium Tax Credit, to clarify that any advance payment of the PTC made on behalf of individuals who did not meet the citizenship or lawful presence requirements must be repaid in full. Taxpayers are required to report the excess advance PTC on their tax returns. If they do not, IRS will address it through post-filing compliance. We will request and review supporting documentation for IRS's reported actions.
    Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to assess whether IRS should require its examiners to verify health care coverage of individuals to determine eligibility for PTC. To do this, IRS should complete its evaluation of the level of noncompliance related to duplicate health insurance coverage. Based on this evaluation and if cost effective, IRS should design and implement formal policies and procedures to routinely identify individuals inappropriately receiving PTC because of their eligibility for or enrollment in health care programs outside of the marketplaces and notify such individuals of their ineligibility for PTC.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: IRS agreed with this recommendation. IRS stated that it developed an Affordable Care Act (ACA) Compliance Strategy in October 2016, which included post-filing checks for the PTC. The IRS must rely upon post refund checks to verify if taxpayers had other healthcare coverage and therefore were not eligible to claim the PTC. For tax year 2017 the IRS plans to implement additional capabilities to evaluate coverage. The IRS will continue to evaluate the results and design and implement cost effective policies and procedures that routinely identify individuals inappropriately receiving PTC, as warranted.
    Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to design and implement procedures in the Internal Revenue Manual (IRM) for examiners in the post-filing compliance units to review tax returns for health insurance coverage for the entire year, and to identify and assess individual shared responsibility payments (SRP) from those who are not appropriately reporting SRPs on their tax returns.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: IRS disagreed with this recommendation. However, IRS stated that, among other things, it has drafted a new IRM section for examiners who are responsible for reviewing tax returns to determine whether health insurance is reflected for the taxpayer for the entire year, and for identifying and assessing SRP on taxpayers who are not appropriately reporting SRP on their tax returns. IRS stated that the IRM section is pending approval by Exam Policy. Although IRS stated that it disagreed with our recommendation, we believe that the actions that IRS described in its response to our draft report would sufficiently address our recommendation if implemented effectively.
    Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to design and implement procedures in the IRM to regularly notify nonfilers of the requirement to file tax returns in order to continue to receive advance PTC in the future.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: The IRS partially agreed with this recommendation. IRS stated that using a research-based approach to evaluate the 2015 tax filing season, it developed a post-compliance process for sending notices to individuals who received advance PTC paid on their behalf in the previous calendar year but failed to file a tax return and also to those who requested an extension to file. IRS stated that being flexible in its approach has allowed IRS to refine the process to improve efficiency and effectiveness. IRS further stated that based on the 2017 research analysis, IRS will determine whether the information should be included in an existing IRM. We agree that IRS should review its process to improve the efficiency and effectiveness of its operations. However, we continue to believe that designing and implementing procedures to regularly notify non-filers of the need to file to continue receiving advance PTC decreases the risk that the ad hoc notification process will not be followed consistently in each filing season.
    Director: Gretta L. Goodwin
    Phone: (202) 512-8777

    5 open recommendations
    Recommendation: To better understand the available opportunities for collecting inmate health care utilization data, BOP should conduct a cost-effectiveness analysis of potential solutions, and take steps toward implementation of the most effective solution.

    Agency: Department of Justice: Bureau of Prisons
    Status: Open

    Comments: In September 2017, BOP stated that it had taken steps to implement a data analytics solution to enable the collection and analysis of health care utilization data. BOP hosted industry presentations and issued a request for information to identify vendors that would be interested and capable of providing a data analytics solution. BOP stated that it will issue a solicitation when funding permits, but did not provide timeframes for when funding might be available.
    Recommendation: To better understand the available opportunities for controlling health care costs, BOP should implement its guidance to conduct "spend analyses" of BOP's health care spending, using data sources already available

    Agency: Department of Justice: Bureau of Prisons
    Status: Open

    Comments: In September 2017, BOP stated that it had taken steps to contract with a health care finance expert to help identify an appropriate medical cost-benefit analysis model and relevant sources of existing data sources. The expert will work with BOP staff once a contract is awarded. BOP did not provide any timeframes for when it expects to award the contract.
    Recommendation: To determine the actual or likely effectiveness of its ongoing or planned health care cost control initiatives, BOP should evaluate the extent to which its initiatives achieve their cost control aim.

    Agency: Department of Justice: Bureau of Prisons
    Status: Open

    Comments: In September 2017, BOP stated that it had taken steps to contract with a health care finance expert to evaluate the cost effectiveness of key health care cost control initiatives. The expert will work with BOP staff once a contract is awarded. BOP did not provide any timeframes for when it expects to award the contract.
    Recommendation: To enhance its strategic planning for and implementation of health care cost control efforts, BOP should incorporate elements of a sound planning approach and (1) establish a means of measuring progress toward and effectiveness of its activities for its current strategic objectives and goals related to controlling health care costs; and (2) identify the resources and investments necessary for implementation of its planned health care cost control initiatives.

    Agency: Department of Justice: Bureau of Prisons
    Status: Open

    Comments: In September 2017, BOP stated that it had taken steps to contract with a health care finance expert to develop target performance metrics along with a cost accounting model to guide the measurement of its health care cost control efforts. The expert will work with BOP staff once a contract is awarded. BOP did not provide any timeframes for when it expects to award the contract.
    Recommendation: To improve the reliability and utility of its Federal Medical Center mission analyses, BOP should document the analyses and findings that underlie its recommendations.

    Agency: Department of Justice: Bureau of Prisons
    Status: Open

    Comments: In September 2017, BOP stated that it will develop and implement a template to document its Federal Medical Center mission and costa analyses. BOP did not provide any timeframes for when it expects to complete this.
    Director: David A. Powner
    Phone: (202) 512-9286

    4 open recommendations
    Recommendation: To assist VA in improving key IT management processes to ensure that investments support the delivery of health care services, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Chief Information Officer to identify performance metrics and associated targets for the goals and objectives in the department's IT strategic plans, including the Information Resources Management strategic plan and the Health Information Strategic Plan, as they relate to the delivery of health IT and the VHA mission.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: In comments on our report, VA concurred with our recommendation and described planned coordination with the Office of Information and Technology and the Veterans Health Administration to develop or revise and maintain performance metrics that support the strategic and health information technology goals and objectives. The department plans to revise performance metrics to align to new goals and objectives by June 2018.
    Recommendation: To assist VA in improving key IT management processes to ensure that investments support the delivery of health care services, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Chief Information Officer to ensure that the department-level investment review structure is implemented as planned and that guidance on the IT governance process is documented and identifies criteria for selecting new investments, and reselecting investments currently operational at VHA.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: In comments on our report, VA concurred with our recommendation and provided meeting minutes for its Portfolio Investment Management Board and a document describing the proposed alignment and interdependencies between the 11 governance boards. We will continue to monitor the implementation of the proposed relationships and review any additional guidance issued that further describes the process used by the governance boards for selecting and reselecting information technology investments.
    Recommendation: To assist VA in improving key IT management processes to ensure that investments support the delivery of health care services, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Chief Information Officer to identify additional performance metrics to align with VHA's core business functions, and then use these metrics to determine the extent to which the department's IT systems support performance of VHA's mission.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: In comments on our report, VA concurred with our recommendation. In addition, the department outlined steps it intends to take to address our recommendation. These steps include developing a set of core metrics to provide continuous input into investment portfolio decisions and establishing a methodology for ensuring that information technology investments are aligned to business needs and that expected outcomes are defined prior to making the investments. The department plans to complete this work by September 2018. We will continue to monitor VA's progress on these efforts.
    Recommendation: To assist VA in improving key IT management processes to ensure that investments support the delivery of health care services, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Chief Information Officer to ensure that unmet IT needs identified by key program areas--pharmacy benefits management, scheduling, and community care--are addressed appropriately and that related business functions are supported by IT systems to the extent required.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: In comments on our report, VA concurred with our recommendation. The department has described its intention to ensure that unmet information technology needs for the pharmacy benefits management, scheduling, and community care program areas are addressed appropriately during fiscal year 2018 budget formulation. We will follow-up with VA to ascertain what needs have been addressed, closed, or reprioritized for each program office during fiscal year 2018.
    Director: Valerie Melvin
    Phone: (202) 512-6304

    6 open recommendations
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to establish and implement a plan for updating the pharmacy system to address the inefficiencies with viewing patient medication data in the Outpatient Pharmacy application and between the pharmacy application and viewers.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and in August 2017 stated that it had identified $4 million in fiscal year 2018 to establish a pharmacy graphical user interface. According to the department, it plans to complete its action in response to this recommendation by June 2018.
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to complete a plan for the implementation of an approach to data standardization that will support the capability for clinicians and pharmacists to view complete DOD data and receive order checks that consistently include DOD data.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred in principle with our recommendation and in August 2017 stated that it plans to implement the electronic health record system that is being deployed by DOD, which will present VA clinicians with complete DOD data and the ability to perform order checks on DOD data. In parallel, the department is continuing and expanding the implementation of data standardization. According to the department, it plans to complete its action in response to this recommendation by October 2019.
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to conduct an assessment to determine to what extent interoperability of VA's pharmacy system with DOD's pharmacy system is impacting transitioning service members.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and in May 2017 stated that the health executive committee would complete an assessment to determine the extent interoperability with DOD's pharmacy system is impacting transitioning service members. According to the department, it planned to complete its actions in response to this recommendation by September 2017. We will update the status of this recommendation when VA provides documentation of its interoperability assessment to us.
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to develop and execute a plan for implementing the capability to send outbound e-prescriptions to non-VA pharmacies, in accordance with National Council for Prescription Drug Programs standards.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and in August 2017 stated that it will review its plan for e-prescribing functionality after it has signed a contract to adopt the electronic health record system that is being deployed by DOD. According to the department, it plans to complete its action in response to this recommendation by March 2018.
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to ensure that the department's evaluation of alternatives for electronic health records includes consideration for additional generation level 3 capability such as navigating from an alert to medication order in the electronic health record system.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and in August 2017 stated that it had entered into contract negotiations to acquire and deploy a level 3 electronic health record system that is expected to address pharmacy functions. The department plans to award this contract in December 2017. We will update the status of this recommendation when VA provides documentation of its evaluation of alternatives to us.
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to reassess the priority for establishing an inventory management capability to monitor and update medication levels and track when to reorder medications.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and in August 2017 stated that it will reassess the prioritization of medication inventory management after a contract for adoption of the electronic health record system is signed in December 2017. According to the department, it plans to complete its action in response to this recommendation by June 2018.
    Director: Persons, Timothy M
    Phone: (202) 512-6412

    4 open recommendations
    Recommendation: The Secretary of Health and Human Services should direct the Commissioner of the Food and Drug Administration to consolidate information from individual diagnostic test labels and make this information available in a form that enables users to more readily compare information across tests.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In August 2017, officials from the Department of Health and Human Services told us that the Food and Drug Administration is working to consolidate and make available on its website information for Zika virus diagnostic tests that have emergency use authorization.
    Recommendation: The Secretary of Health and Human Services should direct the Commissioner of the Food and Drug Administration to require manufacturers to list the identity of comparator assays on their diagnostic test labels.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In August 2017, officials from the Department of Health and Human Services told us that the Food and Drug Administration plans to recommend to sponsors of Zika virus diagnostic tests that they provide a description of the comparator assay.
    Recommendation: The Secretary of Health and Human Services should direct the Director of Centers for Disease Control and Prevention to establish a transparent process to provide CDC diagnostic tests, upon request, to manufacturers that are in the final stages of diagnostic test authorization.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In August 2017, officials from the Department of Health and Human Services told us that the Centers for Disease Control and Prevention (CDC) Technology Transfer Office is working to establish a transparent process that ensures CDC diagnostic tests can be provided to manufacturers.
    Recommendation: The Secretary of Health and Human Services should direct the Director of Centers for Disease Control and Prevention to include information on CDC-developed tests distributed to or shared with public health laboratories on CDC's website, including laboratory developed tests.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In August 2017, officials from the Department of Health and Human Services told us the Centers for Disease Control and Prevention (CDC) provides information on CDC-developed diagnostic tests on the Food and Drug Administration?s (FDA) website. CDC stated that their website will feature a direct link to FDA information on CDC-developed tests. CDC will continue to explore additional outlets for publication of information on CDC-developed diagnostic tests.
    Director: Wise, David J
    Phone: (202) 512-2834

    2 open recommendations
    Recommendation: To improve VA's ability to plan for and facilitate the alignment of its facilities with veteran needs, the Secretary of Veterans Affairs should direct the appropriate offices and administrations to address identified limitations to the SCIP process, including limitations to scoring and approval, and access to information.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA partially concurred with this recommendation. In their 60-day letter dated August 3, 2017, VA noted that it has made process changes in those areas that it concurred with. This includes both access to information, improving communication and timing of SCIP results, and lessoning the administrative burden of providing SCIP documents to SCIP users. For fiscal year (FY) 2018 SCIP, including the projects that were funded, the results were provided prior to the 2018 budget release, and prior to the development of SCIP 2019 business cases. In the past, these results were not released to planners until after the budget was publicly released. In addition, the threshold for inclusion of projects into the SCIP process was raised from $1 M to $3M for the Veterans Health Administration (VHA) nonrecurring maintenance (NRM) projects. This was done to lessen the administrative burden and provide more flexibility to the field to manage their operational needs. Although VA has made some progress towards this recommendation, they have not satisfied the full intent. Specifically, VA has not yet made changes to improve the visibility and prioritization of sequenced projects or the scoring and approval process. VA noted that it disagreed that the SCIP scoring and approval process introduces subjectivity through the use of its business cases, but we will follow up over the next year to see if they made any changes that would help address this portion of the recommendation.
    Recommendation: To improve VA's ability to plan for and facilitate the alignment of its facilities with veteran needs, the Secretary of Veterans Affairs should direct the appropriate offices and administrations to assess the value of VAIP's facility master plans as a facility-planning tool. Based on conclusions from the review, either 1) discontinue the development of VAIP's facility master plans or 2) address the limitations of VAIP's facility master plans.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: In its 60-day letter dated August 3, 2017, VA noted that its VAIP facility master plans have been discontinued while VA pursues a congressionally-directed National Realignment Strategy, which will last a minimum of 18 months. VA will be evaluating service delivery opportunities in each contiguous United States (CONUS) market, to improve the networks of complementary community care providers, best coordinate Veteran healthcare, and move certain components of care into the community when appropriate. Once a National Realignment Plan is submitted and approved by Congress, future facility master plans will be adjusted accordingly, and incorporate pertinent information. Such information will include community care realignment opportunities. We will follow-up with VA to obtain additional information regarding this recommendation.
    Director: Carolyn Yocom
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To help ensure that its efforts to increase patients' electronic access to health information are successful, the Secretary of HHS should direct ONC to develop performance measures to assess outcomes of key efforts related to patients' electronic access to longitudinal health information. Such actions may include, for example, determining whether the number of providers that participate in these initiatives have higher rates of patient access to electronic health information.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help ensure that its efforts to increase patients' electronic access to health information are successful, the Secretary of HHS should direct ONC to use the information these performance measures provide to make program adjustments, as appropriate. Such actions may include, for example, assessing the status of program operations or identifying areas that need improvement in order to help achieve program goals related to increasing patients' ability to access their health information electronically.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    6 open recommendations
    Recommendation: To help VHA achieve its objective of reducing the risk of diversion through effective implementation and oversight of the controlled substance inspection program, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that VA medical facilities have established an additional control procedure, such as an alternate controlled substance coordinator or additional inspectors, to help coordinators meet their responsibilities and prevent missed inspections.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help VHA achieve its objective of reducing the risk of diversion through effective implementation and oversight of the controlled substance inspection program, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that VA medical facilities have established a process where coordinators, in conjunction with appropriate stakeholders (e.g., pharmacy officials), periodically compare facility inspection procedures to VHA's policy requirements and modify facility inspection procedures as appropriate.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help VHA achieve its objective of reducing the risk of diversion through effective implementation and oversight of the controlled substance inspection program, the Secretary of Veterans Affairs should direct the Under Secretary for Health to improve the training of VA medical facility controlled substance coordinators by ensuring the training includes the inspection procedures that VHA requires.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help VHA achieve its objective of reducing the risk of diversion through effective implementation and oversight of the controlled substance inspection program, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that medical facility directors have designed and implemented a process to address nonadherence with program requirements, including documenting the nonadherence and the corrective actions taken to remediate nonadherence or the actions that demonstrate why no remediation is necessary.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help VHA achieve its objective of reducing the risk of diversion through effective implementation and oversight of the controlled substance inspection program, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that networks review their facilities' quarterly trend reports and ensure facilities take corrective actions when nonadherence is identified.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help VHA achieve its objective of reducing the risk of diversion through effective implementation and oversight of the controlled substance inspection program, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that networks monitor their medical facilities' efforts to establish and implement a review process to periodically compare facility inspection procedures to VHA's policy requirements.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Joe Kirschbaum
    Phone: (202) 512-9971

    3 open recommendations
    Recommendation: As DOD plans to respond to a pandemic, the Secretary of Defense should direct the Under Secretary of Defense for Policy and other DOD officials, as appropriate, to use DOD's existing coordination mechanisms with HHS and the Federal Emergency Management Agency (FEMA) to explore opportunities to improve their preparedness and response to a pandemic if DOD's capabilities are limited.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: As HHS plans to respond to a pandemic, the Secretary of Health and Human Services should direct the Assistant Secretary for Preparedness and Response to use HHS's existing coordination mechanisms with DOD and FEMA to explore opportunities to improve their preparedness and response to a pandemic if DOD's capabilities are limited.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: As DHS, through FEMA, plans to respond to a pandemic, the Secretary of Homeland Security should direct the Administrator of FEMA to use FEMA's existing coordination mechanisms with DOD and HHS to explore opportunities to improve their preparedness and response to a pandemic if DOD's capabilities are limited.

    Agency: Department of Homeland Security: Directorate of Emergency Preparedness and Response: Federal Emergency Management Agency
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Diana Maurer
    Phone: (202) 512-8777

    2 open recommendations
    Recommendation: To better ensure grantees' compliance with the Drug-Free Communities Support Program's statutory requirements and to strengthen monitoring of grantee activities, SAMHSA should develop an action plan with time frames for addressing any deficiencies it finds through its reviews and making systemic changes to mitigate deficiencies on a prospective basis to strengthen the grant monitoring process.

    Agency: Department of Health and Human Services: Public Health Service: Substance Abuse and Mental Health Services Administration
    Status: Open

    Comments: As of April 2017, according to the Department of Health and Human Services, SAMHSA is currently in the process of implementing routine audits of all its grant files. SAMHSA will also conduct an audit specifically of DFC files to ensure compliance by the end of summer 2017. Additionally, SAMHSA will offer regular training to government project officers (GPO) on grant report requirements and will ensure DFC GPO participation. Finally, SAMHSA is actively implementing the Grants Enterprise Management System to streamline the grants management process and make the process for maintaining grant files automated. By the end of fall 2017, all newly awarded DFC grants will be in this system. By the end of fall 2018, all active DFC grants will utilize this system.
    Recommendation: To better ensure grantees' compliance with the Drug-Free Communities Support Program's statutory requirements and to strengthen monitoring of grantee activities, SAMHSA should develop and implement a method for ensuring that the grantee status reports it provides to ONDCP are complete and accurate.

    Agency: Department of Health and Human Services: Public Health Service: Substance Abuse and Mental Health Services Administration
    Status: Open

    Comments: As of April 2017, according to the Department of Health and Human Services, SAMHSA will develop a plan to ensure complete and accurate information is provided to ONDCP by the end of summer 2017.
    Director: Brenda S. Farrell
    Phone: (202) 512-3604

    8 open recommendations
    Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to incorporate medical screening questions specific to gambling disorder as part of a systematic screening process across DOD, such as DOD's annual Periodic Health Assessment, for behavioral and mental-health issues.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to update DOD Instruction 1010.04, Problematic Substance Use by DOD Personnel, to explicitly include gambling disorder as defined in the 2013 Diagnostic and Statistical Manual of Mental Disorders.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Secretary of Defense should direct the Secretary of the Army to update Army Regulation 600-85, The Army Substance Abuse Program, to explicitly include gambling disorder.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Secretary of Defense should direct the Secretary of the Navy to update Naval Operations Instruction 5350.4D, Navy Alcohol and Drug Abuse Prevention and Control, to explicitly include gambling disorder.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Secretary of Defense should direct the Secretary of the Air Force to update Air Force Instruction 44-121, Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program, to explicitly include gambling disorder.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Secretary of Defense should direct the Commandant of the Marine Corps to update Marine Corps Order 5300.17, Marine Corps Substance Abuse Program, to explicitly include gambling disorder.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Commandant of the Coast Guard should update Commandant Instruction M6000.1F, Coast Guard Medical Manual, to classify gambling disorder as an addiction and not as an impulse control issue.

    Agency: Department of Homeland Security: United States Coast Guard
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Commandant of the Coast Guard should update Commandant Instruction M1000.10, Coast Guard Drug and Alcohol Abuse Program, to explicitly include gambling disorder.

    Agency: Department of Homeland Security: United States Coast Guard
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Kay E. Brown
    Phone: (202) 512-7215

    1 open recommendations
    Recommendation: To help states effectively address ongoing challenges related to ensuring the appropriate use of psychotropic medications for children in foster care, the Secretary of HHS should consider cost-effective ways to convene state child welfare, Medicaid, and other stakeholders to promote collaboration and information sharing within and across states on psychotropic medication oversight.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS agreed with this recommendation and provided examples of the virtual convening of contingency groups they employed to provide technical assistance and peer to peer networking in child welfare. The agency plans to offer additional technical assistance that is specifically related to the topic of mental health and psychotropic medication. GAO will consider closing the recommendation when the agency completes these efforts.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    2 open recommendations
    including 1 priority recommendation
    Recommendation: To improve care for women veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to strengthen the environment of care inspections process and VHA's oversight of this process by expanding the list of requirements that facility staff inspect for compliance to align with VHA's women's health handbook, ensuring that all patient care areas of the medical facility are inspected as required, clarifying the roles and responsibilities of VA medical facility staff responsible for identifying and addressing compliance, and establishing a process to verify that noncompliance information reported by facilities to VHA Central Office is accurate and complete.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of June 2017, VA has taken some actions to address this recommendation, but additional actions are needed to fully implement it. We will update the status of this recommendation when we receive additional information from VA.
    Recommendation: To improve care for women veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to monitor women veterans' access to key sex-specific care services--mammography, maternity care, and gynecology--under current and future community care contracts. For those key services, monitoring should include an examination of appointment scheduling and completion times, driving times to appointments, and reasons appointments could not be scheduled with community providers.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: As of June 2017, VHA still lacks data and performance measures for the availability under Choice of sex-specific care, such as mammograms, maternity care, or gynecology. In contrast, for another VA care in the community program, PC3 (a program that the Choice third party administrators also administer) VHA collects data and has performance measures to evaluate women veterans' access to mammography and maternity care. To fully implement this recommendation, VHA needs to extend the collection of data to include care delivered through the Choice Program and other community care programs and establish related performance measures.
    Director: Cary Russell
    Phone: (202) 512-5431

    3 open recommendations
    Recommendation: To better position combatant commanders to implement the requirements of DOD Instruction 4715.19 if burn pits become necessary and to assist in planning for waste disposal in future military operations, the Secretary of Defense should direct the combatant commanders of U.S. Africa Command, U.S. European Command, U.S. Pacific Command, and U.S. Southern Command to establish implementation policies and procedures for waste management. Such policies and procedures should include, as applicable, specific organizations within each combatant command with responsibility for ensuring compliance with relevant policies and procedures, including burn pit notification, and, when appropriate, monitoring and reporting on the use of burn pits.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To better understand the long-term health effects of exposure to the disposal of covered waste in burn pits, the Secretary of Defense should direct the Under Secretary of Defense for Acquisition, Technology, and Logistics to, in coordination with the Secretary of Veterans Affairs, specifically examine the relationship between direct, individual, burn pit exposure and potential long-term health-related issues. As part of that examination, consider the results of the National Academies of Sciences, Engineering, and Medicine's report on the Department of Veteran Affairs registry and the methodology outlined in the 2011 Institute of Medicine study that suggests the need to evaluate the health status of service members from their time of deployment over many years to determine their incidence of chronic disease, with particular attention to the collection of data at the individual level, including the means by which that data is obtained.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To better understand the long-term health effects of exposure to the disposal of covered waste in burn pits, the Secretary of Defense should direct the Under Secretary of Defense for Acquisition, Technology, and Logistics to take steps to ensure United States Central Command and other geographic combatant commands, as appropriate, establish processes to consistently monitor burn pit emissions for unacceptable exposures.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Farrell, Brenda S
    Phone: (202) 512-3604

    6 open recommendations
    Recommendation: To fully assess the size and composition of the medical force, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to conduct a new analysis of the required number of active-duty and civilian medical personnel that mitigates known limitations.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To strengthen ongoing efforts to analyze the costs of medical force readiness and establish clinical currency standards, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to take steps to identify and mitigate limitations regarding the standard for maintaining providers' clinical skills, including improving the accuracy of information concerning providers' workload and conducting an analytically rigorous calculation of active-duty providers' time devoted to military-specific responsibilities.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help achieve DOD's goals for transferring health care into its own facilities and increasing the productivity of active-duty medical providers, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to develop a strategy for achieving these goals that reflects the leading practices of effective federal strategic planning.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To strengthen ongoing efforts within DOD to address the Study's recommendations to use the provider model outputs to inform execution of health care delivery and to refine the model for future use, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to modify DOD's model to reflect the military service of the physicians and military treatment facilities included in the model.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To strengthen any future assessments of additional changes to DOD's network of military treatment facilities, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to describe steps taken to assess the reliability of data supporting the assessment, including, at a minimum, the sources of data, data limitations, and efforts to test data reliability.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To strengthen any future assessments of additional changes to DOD's network of military treatment facilities, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to include in any accompanying cost estimates an appropriate level of detail, all significant costs, and an assessment of the reliability of the data supporting the cost estimate.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: David A. Powner
    Phone: (202) 512-9286

    5 open recommendations
    Recommendation: Given the importance of providing accurate and clear information to facilitate congressional decision making and inform the public, the Secretary of Commerce should direct NOAA's Assistant Administrator for Satellite and Information Services to require satellite programs to perform regular availability assessments and use these analyses to inform the flyout charts and support its budget requests.

    Agency: Department of Commerce
    Status: Open

    Comments: NOAA agreed with this recommendation, but has not yet addressed it. We will continue to monitor the agency's actions on this recommendation.
    Recommendation: Given the importance of providing accurate and clear information to facilitate congressional decision making and inform the public, the Secretary of Commerce should direct NOAA's Assistant Administrator for Satellite and Information Services to establish and implement a consistent approach to depicting satellites that are expected to last beyond their design lives.

    Agency: Department of Commerce
    Status: Open

    Comments: NOAA agreed with this recommendation and has taken steps to implement it. The agency updated its flyout chart policy and is in the process of drafting a separate policy to describe how the satellite's extended life is to be predicted and to establish the agency's criteria for publishing the information. This policy is expected to be completed in Fall 2017. We will continue to monitor the agency's actions on this recommendation.
    Recommendation: Given the importance of providing accurate and clear information to facilitate congressional decision making and inform the public, the Secretary of Commerce should direct NOAA's Assistant Administrator for Satellite and Information Services to revise and finalize the draft policy governing how flyout charts are to be updated to address the shortfalls with analysis, accuracy, consistency, and documentation noted in the above recommendations.

    Agency: Department of Commerce
    Status: Open

    Comments: NOAA agreed with this recommendation and has taken steps to implement it. NOAA updated its policy governing how the flyout charts are to be updated. In doing so, the agency updated the policy's roles and responsibilities, guidelines, and its methodology for depicting extended life. However, the policy does not clearly define or describe fuel-limited life and its use, or establish standard artifacts for documenting and supporting planned changes to its flyout chart. We will continue to monitor the agency's actions on this recommendation.
    Recommendation: Given the importance of providing accurate and clear information to facilitate congressional decision making and inform the public, the Secretary of Commerce should direct NOAA's Assistant Administrator for Satellite and Information Services to ensure that flyout chart updates are consistent with supporting data from the program and from satellite availability assessments.

    Agency: Department of Commerce
    Status: Open

    Comments: NOAA agreed with this recommendation, but has not yet demonstrated the steps it is taking to ensure that flyout chart updates are consistent with supporting data. We will continue to monitor the agency's actions on this recommendation.
    Recommendation: Given the importance of providing accurate and clear information to facilitate congressional decision making and inform the public, the Secretary of Commerce should direct NOAA's Assistant Administrator for Satellite and Information Services, for each flyout chart update, to maintain a complete package of documentation on the reasons for any changes and executive approval of the changes.

    Agency: Department of Commerce
    Status: Open

    Comments: NOAA agreed with this recommendation and has taken steps to implement it. Specifically, NOAA provided its March 2017 flyout charts and the associated justification packages. However, NOAA has not established a standard set of artifacts to be included in the justification packages to support changes to its flyout charts. We are working with NOAA to obtain additional justification packages for the next iteration of flyout charts, and will continue to monitor the agency's actions on this recommendation.
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To improve the accessibility and reliability of SNF expenditure data, the Acting Administrator of CMS should take steps to improve the accessibility of SNF expenditure data, making it easier for public stakeholders to locate and use the data.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To improve the accessibility and reliability of SNF expenditure data, the Acting Administrator of CMS should take steps to ensure the accuracy and completeness of SNF expenditure data.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Beryl H. Davis
    Phone: (202) 512-2623

    11 open recommendations
    Recommendation: To improve the design of internal controls over the indirect cost rate-setting process, the Director of CAS should develop a standardized checklist and document procedures in its internal guidance instructing negotiators to use the checklist during negotiation.

    Agency: Department of Health and Human Services: Division of Cost Allocation
    Status: Open

    Comments: HHS concurred with this recommendation. In response, HHS stated that its Cost Allocation Services (CAS) will update and complete standardized checklists and that staff will be instructed to use these checklists by December 31, 2016. We are currently reviewing support received from HHS to determine if we can close the recommendation.
    Recommendation: To improve the design of internal controls over the indirect cost rate-setting process, the Director of CAS should develop detailed internal guidance for the completion and documentation of supervisory review of the indirect cost rate negotiation process to provide reasonable assurance that key control activities have been performed by the negotiators.

    Agency: Department of Health and Human Services: Division of Cost Allocation
    Status: Open

    Comments: HHS concurred with this recommendation. In response, HHS stated that by December 31, 2016, its Cost Allocation Services (CAS) will establish a document outlining standardized review procedures for supervisory review of workpapers and rate agreements. We are currently reviewing support received from HHS to determine if we can close the recommendation.
    Recommendation: To improve the design of internal controls over the indirect cost rate-setting process, the Director of CAS should develop internal guidance for negotiating indirect cost rates with all types of research organizations, including hospitals, as well as universities using the simplified method.

    Agency: Department of Health and Human Services: Division of Cost Allocation
    Status: Open

    Comments: HHS concurred with this recommendation. In response, HHS stated that its Cost Allocation Services (CAS) will update internal guidance for negotiating indirect cost rates with universities using the simplified method by December 31, 2016. This guidance will include an example under the two types of direct cost bases, a salary and wage base and a modified total direct cost base. CAS will develop internal guidance for negotiating with hospitals as soon as possible. We are currently reviewing support received from HHS to determine if we can close the recommendation.
    Recommendation: As NIH-DFAS begins formalizing its internal guidance, the Director of NIH-DFAS should update internal guidance to include key characteristics, such as policy number, purpose of the policy, effective date, and approving official, that are normally included in formal policy and procedures.

    Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health: Office of Management: Office of Acquisition and Logistics Management: Office of Acquisition Management and Policy: Division of Financial Advisory Services
    Status: Open

    Comments: HHS concurred with this recommendation. In response, HHS stated that by December 31, 2016, National Institute of Health's Division of Financial Advisory Services (DFAS) will update internal guidance to include key characteristics that are normally included in formal policy and procedures. NIH-DFAS has finalized three of the five polices, which are effective as of July 1, 2017. The remaining two policies will be finalized by August 31st, 2017. We will continue to monitor the status of this recommendation.
    Recommendation: As NIH-DFAS begins formalizing its internal guidance, the Director of NIH-DFAS should develop detailed procedures for the completion and documentation of supervisory review of the indirect cost rate negotiation process to provide reasonable assurance that key control activities have been performed by the negotiator.

    Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health: Office of Management: Office of Acquisition and Logistics Management: Office of Acquisition Management and Policy: Division of Financial Advisory Services
    Status: Open

    Comments: HHS concurred with this recommendation. In response, HHS stated that the National Institute of Health's Division of Financial Advisory Services (DFAS), will develop detailed procedures for the completion and documentation of supervisory review of the indirect cost rate negotiations process. NIH-DFAS has developed draft internal guidance to address the supervisory review of the indirect cost negotiation process. NIH-DFAS plans to finalize these procedures by August 31, 2017. We will continue to monitor the status of this recommendation.
    Recommendation: As NIH-DFAS begins formalizing its internal guidance, the Director of NIH-DFAS should establish a mechanism for tracking key milestones in the indirect cost rate-setting process, such as when indirect cost rate proposals are due.

    Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health: Office of Management: Office of Acquisition and Logistics Management: Office of Acquisition Management and Policy: Division of Financial Advisory Services
    Status: Open

    Comments: HHS concurred with this recommendations. In response, HHS stated that National Institute of Health's Division of Financial Advisory Services (DFAS) will establish a mechanism for tracking key milestones in the indirect cost rate-setting process. NIH-DFAS has initiatives underway that include moving from paper to electronic submissions of indirect cost proposals and developing a replacement to its Commercial Rate Agreement Distribution Services website. DFAS is looking into the feasibility of incorporating key milestones into these two major initiatives. NIH-DFAS is currently working with a contractor to develop a web based system that will establish a tracking system to account for when indirect cost proposal are due from organizations. The original initiative to enable the electronic submission of indirect cost proposals was modified to incorporate this new requirement. NIH-DFAS anticipates the planned date for implementation of this system to be October 1, 2017. We will continue to monitor the status of this recommendation.
    Recommendation: To improve the design of internal controls over the indirect cost rate-setting process, the Director of ONR should implement the May 2014 policy requiring an annual review of guidance so that internal guidance is updated when changes are made to applicable regulations and procedures to reasonably assure that the guidance reflects current requirements.

    Agency: Department of Defense: Department of the Navy: Office of Naval Research
    Status: Open

    Comments: DOD concurred with this recommendation. In response, DOD stated that the Office of Naval Research (ONR) will comply with its requirement for an annual review of its internal policy on negotiating indirect costs. As of June 15, 2017, no updated information has been provided by the Department of Defense. We will continue to monitor the status of this recommendation.
    Recommendation: To improve the design of internal controls over the indirect cost rate-setting process, the Director of ONR should include in its internal guidance acceptable Defense Contract Audit Agency (DCAA) audit completion time frames and identify supplemental procedures to be performed by negotiators if DCAA cannot perform its audits timely or if DCAA issues a qualified opinion or rescinds one of its previously issued audit opinions, to reasonably assure that the indirect cost rate proposal has been adequately reviewed and the negotiated rate complies with applicable regulations.

    Agency: Department of Defense: Department of the Navy: Office of Naval Research
    Status: Open

    Comments: DOD concurred with this recommendation. In response, DOD stated that the Office of Naval Research's (ONR) internal guidance will be updated to provide more realistic audit report due dates and will include general procedures to be performed by negotiators in the case of untimely audits, qualified opinions, or rescinded opinions. As of June 15, 2017, no updated information has been provided by the Department of Defense. We will continue to monitor the status of this recommendation.
    Recommendation: To improve the design of internal controls over the indirect cost rate-setting process, the Director of ONR should develop detailed procedures for the completion and documentation of supervisory review of the indirect cost rate negotiation process to provide reasonable assurance that required certifications and assurances are obtained and follow-up with the research organization is documented.

    Agency: Department of Defense: Department of the Navy: Office of Naval Research
    Status: Open

    Comments: DOD partially concurred with this recommendation. DOD did not agree that the Office of Naval Research (ONR) lacks procedures to ensure supervisors confirm that negotiators adequately performed and documented key controls. DOD noted that both the primary and secondary supervisors are required to review and approve the Business Clearance Memorandum, which records steps performed by the negotiator. While we agree that the Business Clearance Memorandum documents steps performed by the negotiator, these steps are documented at a high level and do not include detailed procedures for supervisors to follow to reasonably assure that the negotiator has performed and documented all key control activities, such as obtaining all required certifications and assurances. DOD agreed in its response that ONR's Business Clearance Memorandum can be improved and stated that ONR will update it to require the negotiator to cross-reference the review steps to the proposal to facilitate the supervisor's review process. However, it is not clear whether the planned Business Clearance Memorandum revisions will include providing detailed procedures for supervisory review as we recommended. As of June 15, 2017, no updated information has been provided by the Department of Defense. We will continue to monitor the status of this recommendation.
    Recommendation: To improve the design of internal controls over the indirect cost rate-setting process, the Director of ONR should finalize and issue internal guidance for negotiating indirect cost rates with universities and nonprofit organizations, including establishing a time frame for issuance of the internal guidance, to help ensure that the procedures are implemented in a timely manner.

    Agency: Department of Defense: Department of the Navy: Office of Naval Research
    Status: Open

    Comments: DOD concurred with this recommendation. In response, DOD stated that the Office of Naval Research (ONR) is currently updating its internal guidance and currently plans to issue this guidance by December 31, 2016. As of June 15, 2017, no updated information has been provided by the Department of Defense. We will continue to monitor the status of this recommendation.
    Recommendation: To improve the design of internal controls over the indirect cost rate-setting process, the Director of ONR should update ONR's existing process for tracking key milestones in the indirect cost rate-setting process to include information such as when indirect cost rate proposals are overdue and when DCAA's audit reports are due.

    Agency: Department of Defense: Department of the Navy: Office of Naval Research
    Status: Open

    Comments: DOD concurred with this recommendation. In response, DOD stated that the Office of Naval Research will update its existing processes for tracking key milestones to include information such as due dates for rate proposals and DCAA audit reports. As of June 15, 2017, no updated information has been provided by the Department of Defense. We will continue to monitor the status of this recommendation.
    Director: Persons, Timothy M
    Phone: (202) 512-6412

    9 open recommendations
    Recommendation: To understand the extent to which incomplete inactivation occurs and whether incidents are being properly identified, analyzed, and addressed, the Secretary of Health and Human Services should direct the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) to develop clear definitions of inactivation for use within their respective guidance documents that are consistent across the Select Agent Program, NIH's oversight of recombinant pathogens, and the Biosafety in Microbiological and Biomedical Laboratories manual.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2017, the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH) within the Department of Health and Human Service (HHS) are taking steps to address this recommendation. Specifically, in January and March 2017, HHS, in collaboration with the United States Department of Agriculture (USDA), issued updated select agent regulations and guidance that included clear definitions of inactivation and a validated inactivation procedure that are consistent across the Federal Select Agent Program. Additionally, HHS stated in December 2016 that NIH will consider providing clear and consistent definitions of inactivation in future guidance that is harmonized with the select agent regulations. Moreover, NIH and CDC told us they plan to include a new appendix in the revised Biosafety in Microbiological and Biomedical Laboratories manual that specifically addresses the development, validation, and implementation of inactivation protocols, which they anticipate releasing in 2 to 3 years.
    Recommendation: To understand the extent to which incomplete inactivation occurs and whether incidents are being properly identified, analyzed, and addressed, the Secretary of Agriculture should direct APHIS to revise reporting forms to help identify when incidents involving incomplete inactivation occur and analyze the information reported to help identify the causes of incomplete inactivation to mitigate the risk of future incidents.

    Agency: Department of Agriculture
    Status: Open

    Comments: In March 2017, officials from the Federal Select Agent Program told us that they are in the process of modifying the program's incident reporting form to include reporting of inactivation failures, with completion anticipated by summer 2017.
    Recommendation: To understand the extent to which incomplete inactivation occurs and whether incidents are being properly identified, analyzed, and addressed, the Secretary of Health and Human Services should direct CDC and NIH to revise reporting forms within their respective areas of oversight to help identify when incidents involving incomplete inactivation occur and analyze the information reported to help identify the causes of incomplete inactivation to mitigate the risk of future incidents.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In March 2017, officials from the Federal Select Agent Program told us that they are in the process of modifying the program's incident reporting form to include reporting of inactivation failures, with completion anticipated by summer 2017. In addition, in August 2016, the National Institutes of Health (NIH) revised its template for reporting incidents subject to the NIH Guidelines to include a specific checkbox for entities to identify incidents that involve incomplete inactivation.
    Recommendation: To increase scientific information on inactivation and viability testing, the Secretaries of Health and Human Services and Agriculture should coordinate research efforts and take actions to help close gaps in the science of inactivation and viability testing across high-containment laboratories.

    Agency: Department of Agriculture
    Status: Open

    Comments: In March 2017, United States Department of Agriculture (USDA) officials stated that the department, in coordination with the Department of Health and Human Services (HHS), has examined current gaps related to inactivation and are in the process of taking steps to increase research on applied biosafety, in part to improve scientific understanding of processes for inactivation in high-containment laboratories. We are waiting for documentation and timeframes for implementation.
    Recommendation: To increase scientific information on inactivation and viability testing, the Secretaries of Health and Human Services and Agriculture should coordinate research efforts and take actions to help close gaps in the science of inactivation and viability testing across high-containment laboratories.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In March 2017, Department of Health and Human Services (HHS) officials stated that the department, in coordination with the United States Department of Agriculture (USDA), has examined current gaps related to inactivation and are in the process of taking steps to increase research on applied biosafety, in part to improve scientific understanding of processes for inactivation in high-containment laboratories. We are waiting for documentation and timeframes for implementation.
    Recommendation: To help ensure that inactivation protocols are scientifically sound and are effectively implemented, the Secretary of Health and Human Services should direct CDC and NIH to create comprehensive and consistent guidance for the development, validation, and implementation of inactivation protocols--to include the application of safeguards--across the Select Agent Program, NIH's oversight of recombinant pathogens, and the Biosafety in Microbiological and Biomedical Laboratories manual.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In March 2017, the Department of Health and Human Services (HHS), in collaboration with the United States Department of Agriculture (USDA), issued Federal Select Agent Program guidance on the inactivation of select agents and toxins. According to HHS, this guidance is intended to provide additional information to regulated entities to assist them in meeting new requirements for rendering samples with select agents as non-viable. HHS also stated that the Federal Select Agent Program will continue to work with other federal agencies to ensure that the federal government is addressing inactivation in a consistent manner. In addition, according to HHS, the National Institutes of Health (NIH) will consider providing clear and consistent guidance related to inactivation that is harmonized with the Federal Select Agent Program as appropriate. As of March 2017, NIH and the Centers for Disease Control and Prevention (CDC) were in the process of revising the Biosafety in Microbiological and Biomedical Laboratories manual to include a new appendix that addresses the development, validation, and implementation of inactivation protocols. HHS plans to release the updated manual in 2 to 3 years.
    Recommendation: To help ensure that dangerous pathogens can be located in the event there is an incident involving incomplete inactivation, the Secretary of Health and Human Services should direct the Directors of CDC and NIH, when updating the Biosafety in Microbiological and Biomedical Laboratories manual, to include guidance on documenting the shipment of inactivated material.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The Department of Health and Human Services (HHS) stated in March 2017 that the National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) are in the process of revising the Biosafety in Microbiological and Biomedical Laboratories manual to include a new appendix that addresses inactivation methods, including guidance on documenting the shipment of inactivated material by 2020. HHS plans to release the updated manual in 2 to 3 years.
    Recommendation: To help ensure more consistent enforcement for violations involving incomplete inactivation of select agents, the Secretary of Agriculture should direct APHIS to develop and implement consistent criteria and documentation requirements for referring violations to investigative entities and enforcing regulations related to incidents involving incomplete inactivation.

    Agency: Department of Agriculture
    Status: Open

    Comments: In September 2017, the Federal Select Agent Program finalized a document that provides criteria on when to refer violations and options for enforcement. The document categorizes regulatory departures, grouped by level of risk, along a spectrum of severity with associated enforcement options. The program continues to develop associated documentation requirements for referring violations to investigative entities and enforcing regulations.
    Recommendation: To help ensure more consistent enforcement for violations involving incomplete inactivation of select agents, the Secretary of Health and Human Services should direct CDC to develop and implement consistent criteria and documentation requirements for referring violations to investigative entities and enforcing regulations related to incidents involving incomplete inactivation.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In September 2017, the Federal Select Agent Program finalized a document that provides criteria on when to refer violations and options for enforcement. The document categorizes regulatory departures, grouped by level of risk, along a spectrum of severity with associated enforcement options. In addition, the Centers for Disease Control and Prevention worked with the Department of Health and Human Services (HHS) Office of Inspector General (OIG) to develop a policy document that outlines criteria for referring violations to the HHS OIG. One of the criterion for referral is any departure from the select agent regulations that creates a danger to public health and safety. This policy document was finalized in June 2017. The program continues to develop associated documentation requirements for referring violations to investigative entities and enforcing regulations.
    Director: Gregory C. Wilshusen
    Phone: (202) 512-6244

    5 open recommendations
    Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should update security guidance for covered entities and business associates to ensure that the guidance addresses implementation of controls described in the National Institute of Standards and Technology Cybersecurity Framework.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with the recommendation and plans to implement it. Subsequent to the agency stating that is has taken action, we plan to verify whether implementation has occurred.
    Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should update technical assistance that is provided to covered entities and business associates to address technical security concerns.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with the recommendation and plans to implement it. Subsequent to the agency stating that is has taken action, we plan to verify whether implementation has occurred.
    Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should revise the current enforcement program to include following up on the implementation of corrective actions.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS neither concurred nor nonconcurred with the recommendation but plans to implement it. Subsequent to the agency stating that is has taken action, we plan to verify whether implementation has occurred.
    Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should establish performance measures for the Office of Civil Rights (OCR) audit program.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with the recommendation and plans to implement it. Subsequent to the agency stating that is has taken action, we plan to verify whether implementation has occurred.
    Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should establish and implement policies and procedures for sharing the results of investigations and audits between OCR and Centers for Medicare & Medicaid Services to help ensure that covered entities and business associates are in compliance with the Health Insurance Portability and Accountability Act of 1996 and the Health Information Technology for Economic and Clinical Health Act.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS neither concurred nor nonconcurred with the recommendation but plans to implement it. Subsequent to the agency stating that is has taken action, we plan to verify whether implementation has occurred.
    Director: Kathleen M. King
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To improve available data about the direct care workforce, the Acting Administrator of the Health Resources and Services Administration should take steps to produce projections of direct care workforce supply and demand and develop methods to address data limitations in order to do so.

    Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
    Status: Open

    Comments: HHS concurred with this recommendation, agreeing that developing projections of the direct care workforce is timely and important. Since the release of the report, HHS's Health Resources and Services Administration (HRSA) published a fact sheet presenting national demand projections for nursing assistants and home health aides. HRSA also reported awarding a contract to develop a projection model for the supply, demand, and distribution of long-term service and support providers. The agency expects reports from this model to be available in 2018.
    Director: Gretta L. Goodwin
    Phone: (202) 512-8777

    2 open recommendations
    including 1 priority recommendation
    Recommendation: To enhance the clarity and transparency of sexual violence data that is reported to the public, the Secretary of Education should direct the Assistant Secretary for the Office of Postsecondary Education, the Secretary of Health and Human Services should direct the Director of Centers for Disease Control and Prevention, and the Attorney General should direct the Director of the Bureau of Justice Statistics to make information on the acts of sexual violence and contextual factors that are included in their measurements of sexual violence publicly available. This effort could entail revising their definitions of key terms used to describe sexual violence so that the definitions match the measurements of sexual violence.

    Agency: Department of Justice
    Status: Open

    Comments: In October 2016, OJP's Bureau of Justice Statistics (BJS) reported that beginning with reports and data files released in calendar year 2017, BJS plans to provide additional information on how sexual violence is defined, to ensure that the measures and definitions are clear and consistent, to improve understanding by users at all levels. Furthermore, BJS reported that they will provide definitions and the exact computer code used to construct the measures of sexual violence. Further, according to BJS, in October 2016 the Acting Director of BJS established an internal Rape and Sexual Assault working group tasked with assessing all BJS data collections; identifying any differences that may exist across data collection efforts; consulting with other federal agencies and subject matter experts; and making recommendations to the Acting Director of BJS to correct any issues identified. The working group met monthly through February 2017, and was comprised of a senior statistical advisor, a statistical policy advisor, and statistical staff from the Victimization Statistics, Corrections Statistics, and Institutional Research and Special Projects units within BJS. In August 2017, BJS officials reported that they are planning to release the 2016 Criminal Victimization Bulletin in late 2017 with additional information on the definition of sexual violence. Also the Rape and Sexual Assault working group provided a detailed set of recommendations to the BJS Acting Director and BJS has convened the working group to develop an implementation plan. BJS stated that their next update would be in early CY 2018 to allow for the release of the report and details on the implementation plan.
    Recommendation: To help lessen confusion among the public and policy makers regarding federal data on sexual violence, the Director of OMB should establish a federal interagency forum on sexual violence statistics. The forum should consider the broad range of differences across the data collection efforts to assess which differences enhance or hinder the overall understanding of sexual violence in the United States.

    Agency: Executive Office of the President: Office of Management and Budget
    Status: Open
    Priority recommendation

    Comments: In March 2017, OMB stated that the Department of Justice's Bureau of Justice Statistics and the Department of Health and Human Services' Centers for Disease Control and Prevention are working together to conduct research on how data collection methodologies, including how questions are asked, affect the measurement of sexual violence in the context of each agency's programmatic needs. OMB reiterated that this research is not far enough along to warrant the investment of resources to establish a formal interagency working group. OMB stated that it has taken steps to enhance collaboration among the agencies, including facilitating discussion of data collection parameters that affect sexual violence reporting. This recommendation was included in the 2017 DOF report, and in August and September 2017, GAO reached out to OMB for the status on their efforts to address the recommendation. As of 9/18/17, OMB had not responded to inquiries.
    Director: Brenda S. Farrell
    Phone: (202) 512-3604

    7 open recommendations
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to assess the Triad of Care model's effectiveness in light of the changes in WTU diagnoses and take the appropriate action.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to exercise oversight responsibility to track full adherence to selection processes for squad leaders and platoon sergeants, including the requirement to conduct interviews for these positions.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to develop a mechanism to conduct post-training assessments on squad leaders and platoon sergeants' application of training to the work environment and incorporate the results into the training program.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to develop plans to adjust staff levels, if needed, to accommodate a potential future surge in demand.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to establish a process that assigns oversight responsibility for tracking instances in which Commanders make exceptions to WTU entrance criteria so that the Army Surgeon General is aware of the extent Commanders' decisions are consistent with program goals.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to develop and implement an approach and associated procedures for providing senior leadership, such as the Warrior Transition Command, with complaints information concerning the WTU program and WTU soldiers.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help ensure the best use of resources for managing the medical care of soldiers recovering from serious medical conditions, the Secretary of the Army should direct the Chief of the Army Reserve, in conjunction with the Army Surgeon General, to develop an analysis that compares the costs and benefits of maintaining the current system of Community Care Units with the costs and benefits of expanding the Reserve Component Managed Care program.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To help the Department of Health and Human Services ensure accuracy in Part B drug payment rates, Congress should consider requiring all manufacturers of Part B drugs paid at ASP, not only those with Medicaid drug rebate agreements, to submit sales price data to CMS, and ensure that CMS has authority to request source documentation to periodically validate all such data.

    Agency: Congress
    Status: Open

    Comments: As of August 2017, no action has been taken on this Matter for Congressional Consideration.
    Recommendation: CMS should periodically verify the sales price data submitted by a sample of drug manufacturers by requesting source documentation from manufacturers to corroborate the reported data, either directly or by working with the HHS Office of Inspector General as necessary.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: In its comments on a draft of this report, HHS concurred with this recommendation. HHS stated that it will continue to work with the Office of Inspector General (OIG) as appropriate to collect source documentation from drug manufacturers and take action as may be warranted. HHS also stated that OIG reviews and compares the submitted average sales price (ASP) to the average manufacturer price (AMP) for Medicare Part B drugs and CMS has the authority to adjust ASP-based payment amounts when the difference between the two rates reaches a certain threshold. We do not consider this recommendation closed because CMS only collects source documentation from manufacturers under very limited circumstances (e.g., when there are obvious inconsistencies in the data submitted by manufacturers). CMS does not periodically request source documentation, such as sales invoices, from a sample of drug manufacturers to verify that the reported data reflect actual sales prices. As of August 17, 2017, CMS has not provided any additional information about actions to address this recommendation.
    Director: Marcia Crosse
    Phone: (202) 512-7114

    10 open recommendations
    Recommendation: To increase awareness of the health and legal consequences of FGM/C among visa recipients, the Secretary of State should update the Foreign Affairs Manual to require posts located in countries where FGM/C is commonly practiced to directly provide information about FGM/C to nonimmigrant visa recipients in the same manner as is done for immigrant visa recipients.

    Agency: Department of State
    Status: Open

    Comments: The Department of State (State) concurred with this recommendation, and noted in a September 2016 update that it will expand the pool of visa applicants who will receive information on FGM/C. Specifically, once its transition to providing paperwork electronically during the visa application process is complete, State will directly distribute the fact sheet on FGM/C to both immigrant and nonimmigrant visa recipients. According to State, both immigrant and nonimmigrant visa recipients will have to certify that they have read and understood the fact sheet on FGM/C before signing and submitting their respective visa applications. As of August 2017, State has not yet completed these actions.
    Recommendation: To increase awareness of the health and legal consequences of FGM/C among visa recipients, the Secretary of State should update the Foreign Affairs Manual to require posts located outside of the countries where FGM/C is commonly practiced to directly provide information on FGM/C to immigrant and nonimmigrant visa recipients who are nationals of countries where FGM/C is commonly practiced.

    Agency: Department of State
    Status: Open

    Comments: The Department of State (State) concurred with this recommendation, and noted in a September 2016 update that it will expand the pool of visa applicants who will receive information on FGM/C. Specifically, once its transition to providing paperwork electronically during the visa application process is complete, State will directly distribute the fact sheet on FGM/C to both immigrant and nonimmigrant visa recipients who are from or were nationals of a country where FGM/C is commonly practiced. State noted that this change will ensure the widest distribution possible by providing all individuals from countries where FGM/C is commonly practiced with access to the fact sheet on FGM/C regardless of place of application or visa recipient type. As of August 2017, State has not yet completed these actions.
    Recommendation: To make the best use of federal resources directed toward combating FGM/C in the United States, the Attorney General and the Secretaries of Education, Health and Human Services, Homeland Security, and State should each develop a written plan that describes the agency's approach for conducting education and outreach to key stakeholders in the United States regarding FGM/C.

    Agency: Department of Education
    Status: Open

    Comments: The Department of Education (Education) concurred with this recommendation, and noted in a September 2016 update that it will develop a written plan for disseminating relevant FGM/C resources to the agency?s key stakeholder groups. As of August 2017, Education reported that action is still pending.
    Recommendation: To make the best use of federal resources directed toward combating FGM/C in the United States, the Attorney General and the Secretaries of Education, Health and Human Services, Homeland Security, and State should each develop a written plan that describes the agency's approach for conducting education and outreach to key stakeholders in the United States regarding FGM/C.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The Department of Health and Human Services (HHS) concurred with this recommendation, and noted in a September 2016 update that various HHS offices and agencies are working together to develop a written plan for its approaches to addressing FGM/C. In August 2017, HHS reported that once a key leadership position has been filled, it will provide more information on developing a written plan.
    Recommendation: To make the best use of federal resources directed toward combating FGM/C in the United States, the Attorney General and the Secretaries of Education, Health and Human Services, Homeland Security, and State should each develop a written plan that describes the agency's approach for conducting education and outreach to key stakeholders in the United States regarding FGM/C.

    Agency: Department of Justice
    Status: Open

    Comments: The Department of Justice (DOJ) concurred with this recommendation, and noted in a September 2016 update that the Human Rights and Special Prosecutions Section of its Criminal Division is taking the lead on developing a written plan on its FGM/C outreach and awareness efforts. As of August 2017, DOJ has not yet developed a written plan.
    Recommendation: To make the best use of federal resources directed toward combating FGM/C in the United States, the Attorney General and the Secretaries of Education, Health and Human Services, Homeland Security, and State should each develop a written plan that describes the agency's approach for conducting education and outreach to key stakeholders in the United States regarding FGM/C.

    Agency: Department of State
    Status: Open

    Comments: The Department of State (State) did not concur with our recommendation, and, as of August 2017, has not indicated that it would implement this recommendation.
    Recommendation: To make the best use of federal resources directed toward combating FGM/C in the United States, the Attorney General and the Secretaries of Education, Health and Human Services, Homeland Security, and State should each communicate the plan with other relevant federal agencies and stakeholder groups, as appropriate.

    Agency: Department of Education
    Status: Open

    Comments: The Department of Education (Education) concurred with this recommendation, and noted in a September 2016 update that it will develop a written plan for disseminating relevant FGM/C resources to the agency?s key stakeholder groups and will explore how to best communicate and coordinate efforts at the federal level. As of August 2017, Education reported that action is still pending.
    Recommendation: To make the best use of federal resources directed toward combating FGM/C in the United States, the Attorney General and the Secretaries of Education, Health and Human Services, Homeland Security, and State should each communicate the plan with other relevant federal agencies and stakeholder groups, as appropriate.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The Department of Health and Human Services (HHS) concurred with this recommendation, and noted in a September 2016 update that various HHS offices and agencies are working together to develop a written plan for its approaches to addressing FGM/C. HHS also noted that it would share this plan with other federal partners and key stakeholders. In August 2017, HHS reported that once a key leadership position has been filled, it will provide more information on disseminating a written plan.
    Recommendation: To make the best use of federal resources directed toward combating FGM/C in the United States, the Attorney General and the Secretaries of Education, Health and Human Services, Homeland Security, and State should each communicate the plan with other relevant federal agencies and stakeholder groups, as appropriate.

    Agency: Department of Justice
    Status: Open

    Comments: The Department of Justice (DOJ) concurred with this recommendation, and noted in a September 2016 update that the Human Rights and Special Prosecutions Section of its Criminal Division is taking the lead on developing a written plan on its FGM/C outreach and awareness efforts. DOJ also noted that it would communicate its written plan with other relevant federal agencies and stakeholder groups, as appropriate. As of August 2017, DOJ has not yet disseminated a written plan.
    Recommendation: To make the best use of federal resources directed toward combating FGM/C in the United States, the Attorney General and the Secretaries of Education, Health and Human Services, Homeland Security, and State should each communicate the plan with other relevant federal agencies and stakeholder groups, as appropriate.

    Agency: Department of State
    Status: Open

    Comments: The Department of State (State) did not concur with our recommendation, and, as of August 2017, has not indicated that it would implement this recommendation.
    Director: John Neumann
    Phone: (202) 512-3841

    9 open recommendations
    including 2 priority recommendations
    Recommendation: To reduce pre-award administrative workload and costs, particularly for applications that do not result in awards, the Secretary of Energy, the NASA Administrator, and the Secretary of Health and Human Services should conduct agency-wide reviews of possible actions, such as further use of preliminary proposals, to postpone pre-award requirements until after a preliminary decision about an applicant's likelihood of funding and, through OSTP's Research Business Models working group, coordinate and report on these efforts.

    Agency: Department of Energy
    Status: Open

    Comments: As of February 2017, DOE stated that it remained committed to addressing this recommendation. DOE outlined several steps it planned to take, such as participating in interagency meetings, but it did not indicate whether it has taken these steps.
    Recommendation: To reduce pre-award administrative workload and costs, particularly for applications that do not result in awards, the Secretary of Energy, the NASA Administrator, and the Secretary of Health and Human Services should conduct agency-wide reviews of possible actions, such as further use of preliminary proposals, to postpone pre-award requirements until after a preliminary decision about an applicant's likelihood of funding and, through OSTP's Research Business Models working group, coordinate and report on these efforts.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: According to HHS, NIH is considering the feasibility of an approach to streamline its application process. As of May 2017, HHS anticipated implementing this recommendation by early fiscal year 2019.
    Recommendation: To reduce pre-award administrative workload and costs, particularly for applications that do not result in awards, the Secretary of Energy, the NASA Administrator, and the Secretary of Health and Human Services should conduct agency-wide reviews of possible actions, such as further use of preliminary proposals, to postpone pre-award requirements until after a preliminary decision about an applicant's likelihood of funding and, through OSTP's Research Business Models working group, coordinate and report on these efforts.

    Agency: National Aeronautics and Space Administration
    Status: Open

    Comments: As of February 2017, NASA anticipated implementing this recommendation by September 2017. NASA stated that it is working with other federal agencies to identify best practices for reducing the administrative burden to applicants and will assess the impact these practices have on the quality of applications so that NASA can continue to meet its mission.
    Recommendation: To better target requirements on areas of greatest risk, while maintaining accountability over grant funds, the Secretary of Health and Human Services, as part of the planned evaluation of the HHS regulation governing financial conflicts of interest in NIH-funded research, should evaluate options for targeting requirements on areas of greatest risk for researcher conflicts, including adjusting the threshold and types of financial interests that need to be disclosed and the timing of disclosures.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS stated that, as of May 2017, NIH was proceeding with plans to assess the financial conflict of interest regulation, including how to reduce administrative burden on researchers while maintaining the integrity and credibility of research findings.
    Recommendation: To better target requirements on areas of greatest risk, while maintaining accountability over grant funds, the Director of OMB, as part of OMB's planned evaluation of the Uniform Guidance, should evaluate options for targeting requirements for research grants to universities, including requirements for purchases and subrecipient monitoring, on areas of greatest risk for improper use of research funds.

    Agency: Executive Office of the President: Office of Management and Budget
    Status: Open
    Priority recommendation

    Comments: As of August 2017, OMB had not provided information on steps it has taken to implement this recommendation.
    Recommendation: To further standardize administrative research requirements, the Secretary of Energy, the NASA Administrator, the Secretary of Health and Human Services, and the Director of NSF should coordinate through Office of Science and Technology Policy's (OSTP) Research Business Models working group to identify additional areas where they can standardize requirements and report on these efforts.

    Agency: Department of Energy
    Status: Open

    Comments: In January 2017, the American Innovation and Competitiveness Act was signed into law, requiring the Office of Management and Budget, in coordination with the Office of Science and Technology Policy, to establish an interagency working group to reduce administrative workload and costs while protecting the transparency of and accountability for federally funded research. As of March 2017, DOE, HHS, NASA, and NSF stated that, as part of their efforts to implement GAO's recommendation, they would coordinate with other research funding agencies through this interagency working group.
    Recommendation: To further standardize administrative research requirements, the Secretary of Energy, the NASA Administrator, the Secretary of Health and Human Services, and the Director of NSF should coordinate through Office of Science and Technology Policy's (OSTP) Research Business Models working group to identify additional areas where they can standardize requirements and report on these efforts.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In January 2017, the American Innovation and Competitiveness Act was signed into law, requiring the Office of Management and Budget, in coordination with the Office of Science and Technology Policy, to establish an interagency working group to reduce administrative workload and costs while protecting the transparency of and accountability for federally funded research. As of March 2017, DOE, HHS, NASA, and NSF stated that, as part of their efforts to implement GAO's recommendation, they would coordinate with other research funding agencies through this interagency working group.
    Recommendation: To further standardize administrative research requirements, the Secretary of Energy, the NASA Administrator, the Secretary of Health and Human Services, and the Director of NSF should coordinate through Office of Science and Technology Policy's (OSTP) Research Business Models working group to identify additional areas where they can standardize requirements and report on these efforts.

    Agency: National Aeronautics and Space Administration
    Status: Open
    Priority recommendation

    Comments: In January 2017, the American Innovation and Competitiveness Act was signed into law, requiring the Office of Management and Budget, in coordination with the Office of Science and Technology Policy, to establish an interagency working group to reduce administrative workload and costs while protecting the transparency of and accountability for federally funded research. As of March 2017, DOE, HHS, NASA, and NSF stated that, as part of their efforts to implement GAO's recommendation, they would coordinate with other research funding agencies through this interagency working group.
    Recommendation: To further standardize administrative research requirements, the Secretary of Energy, the NASA Administrator, the Secretary of Health and Human Services, and the Director of NSF should coordinate through Office of Science and Technology Policy's (OSTP) Research Business Models working group to identify additional areas where they can standardize requirements and report on these efforts.

    Agency: National Science Foundation
    Status: Open

    Comments: In January 2017, the American Innovation and Competitiveness Act was signed into law, requiring the Office of Management and Budget, in coordination with the Office of Science and Technology Policy, to establish an interagency working group to reduce administrative workload and costs while protecting the transparency of and accountability for federally funded research. As of March 2017, DOE, HHS, NASA, and NSF stated that, as part of their efforts to implement GAO's recommendation, they would coordinate with other research funding agencies through this interagency working group.
    Director: Maurer, Diana C
    Phone: (202) 512-8777

    2 open recommendations
    Recommendation: To ensure that costs savings estimates are reliable, the Director of the USMS should direct its Prisoner Operations Division to develop reliable methods for estimating cost savings and validating reported savings achieved.

    Agency: Department of Justice: United States Marshals Service
    Status: Open

    Comments: In May 2016, we reported on United States Marshals Service's (USMS) actions to reduce prisoner-related costs from fiscal years 2010 through 2015. During the course of our review, we found that while USMS implemented actions that it reports have continued to save prisoner-related costs, USMS's methods to determine savings for certain actions were not reliable. For example, USMS identified $375 million in savings from the alternatives to pre-trial detention program for fiscal years 2010 through 2015, but did not verify the data or methodology used to develop the estimate or provide documentation supporting its reported savings for fiscal years 2012 onward. Consequently, we recommended that USMS direct its prisoner operations division to develop reliable methods for estimating cost savings and validating reports savings achieved. USMS concurred with our recommendation. In July 2016, USMS provided more information about how it would address the recommendation by confirming that its future cost savings estimates would be consistent with OMB guidelines for conducting benefit-cost analyses and GAO-identified practices for assessing the reliability of computer-processed data. Aligning USMS estimates with these identified practices would better position the agency to assess the effectiveness of its cost savings efforts. As USMS develops such mechanisms, we will request and consider documentation and other evidence to determine that USMS has implemented this recommendation.
    Recommendation: To enable USMS to more consistently identify deficiencies and monitor corrective actions, the Director of the USMS should establish a mechanism to aggregate and analyze the results of annual district self-assessments.

    Agency: Department of Justice: United States Marshals Service
    Status: Open

    Comments: In May 2016, we reported on United States Marshals Service's (USMS) actions to design systems to help identify cost savings opportunities. During the course of our review, we found that USMS has designed several systems for identifying cost savings, including, for example, developing a strategic plan and guidance for district officials that reinforce policies to provide for the safe, secure, and cost-effective containment of its prisoners. In addition, USMS requires districts to conduct annual self-assessments of their procedures to identify any deficiencies which could lead to cost savings. However, USMS cannot aggregate and analyze the results of the assessments across districts. As a result, we recommended that USMS establish a mechanism to aggregate and analyze the results of annual district self-assessments. USMS concurred with our recommendation. In July 2016, USMS informed us that the agency will develop a method to aggregate and analyze the results of the annual district self-assessments. However, it has not provided information on its plans or timelines to implement the recommendation. As USMS develops such mechanisms, we will consider documentation and other evidence to determine that USMS has implemented this recommendation.
    Director: Melissa Emrey-Arras
    Phone: (617) 788-0534

    7 open recommendations
    Recommendation: To help foster and unaccompanied homeless youth better navigate the college admissions and federal student aid processes, the Secretaries of Education and HHS should jointly study potential options for encouraging and enabling child welfare caseworkers, McKinney-Vento homeless youth liaisons, and other adults who work with these youth to more actively assist them with college planning.

    Agency: Department of Education
    Status: Open

    Comments: In 2017, Education reported that it is continuing its efforts to address the recommendation. In May 2016, Education, working with the Department of Health and Human Services, issued a Foster Youth Transition Toolkit, which addresses both financial aid and college admissions processes. The toolkit was written for youth in or formerly in foster care rather than for professionals who serve these youth. Education noted that it had also posted a Homeless Youth Fact sheet for teachers and other professionals on its website in July. Education said that it will continue to work with HHS and the National Association for the Education of Homeless Children and Youth about college admissions and federal student aid processes for foster and unaccompanied homeless youth. Education also plans to conduct a technical assistance webinar for McKinney-Vento homeless youth liaisons and to provide technical assistance for other programs. Making such information available on Education's website is an encouraging step, as are plans to conduct webinars for professionals who work with homeless youth. We look forward to the implementation of these plans. However, we continue to believe that HHS and Education should consider ways to encourage more active college planning efforts among professionals who work with homeless and foster youth that consider professional staff's competing goals and priorities and multiple responsibilities.
    Recommendation: To help foster and unaccompanied homeless youth better navigate the college admissions and federal student aid processes, the Secretaries of Education and HHS should jointly study potential options for encouraging and enabling child welfare caseworkers, McKinney-Vento homeless youth liaisons, and other adults who work with these youth to more actively assist them with college planning.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS, working with the Department of Education, issued a Foster Youth Transition Toolkit in May 2016 which encourages current and former foster youth to pursue college and addresses both financial aid and college admissions processes. The toolkit was written for youth in or formerly in foster care, and HHS considers it a resource for unaccompanied homeless youth as well as for the adults who serve these youth. Making such information available through this joint publication is an encouraging step. However, child welfare caseworkers, school homelessness liaisons, and other professionals who work with homeless and foster youth have competing goals and priorities and multiple responsibilities. To encourage and facilitate college planning and admissions efforts, Education and HHS would need to carefully consider professional staff's workloads, responsibilities, and training needs, among other issues, and develop some options for encouraging college planning efforts among professionals in these programs who work with homeless and foster youth. HHS did not provide an update for FY 2017.
    Recommendation: To help foster and unaccompanied homeless youth, as well as adults who assist these youth, better navigate the federal student aid process and obtain information about college resources, the Secretary of Education, in consultation with the Secretary of HHS, should create webpages directed to homeless and foster youth so they can more easily find tailored and centralized information about available federal and other resources, such as Pell Grants, Chafee Education and Training Voucher Program (Chafee ETV Vouchers), and waivers for college admission tests.

    Agency: Department of Education
    Status: Open

    Comments: In 2017, Education reported that it is continuing its efforts to address the recommendation. In addition to having a webpage about foster youth, Education noted that in April 2016 it had created a new webpage with resources for homeless children and youth. In July 2016, Education developed and posted online a Foster Care Transition Toolkit and a Fact Sheet on federal student aid for homeless youth that is available through its resources webpage. The development and posting of these materials on the agency's website offers helpful resources to foster and homeless youth; however, Education should also make it easier for these youth, who often lack adult support, to find these documents easily--such as by referring to them on the page that says who is eligible for federal student aid--without lengthy searching of the Website.
    Recommendation: To help college financial aid administrators more effectively implement eligibility rules for unaccompanied homeless youth, the Secretary of Education should make available an optional worksheet or form that college financial aid administrators can voluntarily use to document unaccompanied homeless youth status or encourage the use of existing forms that are available.

    Agency: Department of Education
    Status: Open

    Comments: Education agreed that it would be helpful to make forms developed by outside organizations knowledgeable about homelessness issues available for financial aid administrators to use for documenting the status of unaccompanied homeless youth. Education also said that it plans to highlight the availability of these forms and provide guidance at its annual conference and in updates to the Federal Student Aid Handbook. Education noted that it will not endorse the use of a specific form but that it will highlight forms that already exist that may be useful to financial aid administrators. In 2017, Education reported that it is continuing its efforts to address the recommendation. We look forward to Education making such forms available for college financial aid administrators so that they can more effectively implement eligibility rules for unaccompanied homeless youth.
    Recommendation: To help homeless youth more easily access federal student aid, the Secretary of Education should clarify its guidance to financial aid administrators and students about whether financial aid administrators should accept any unaccompanied homeless youth determination provided by McKinney-Vento homeless liaisons or other authorized officials even if a student is not in high school or receiving program services.

    Agency: Department of Education
    Status: Open

    Comments: In 2017, Education reported that it is continuing its efforts to address the recommendation. In June 2016, Education posted questions and answers about federal student for homeless youth on its website and in July, the agency posted a fact sheet about Homeless Youth on its webpage for teachers and other professional staff. However, neither document states whether financial aid administrators should accept any unaccompanied homeless youth determination provided by McKinney-Vento liaisons or authorized officials even if a student is not in high school or receiving program services. In July 2016, Education issued guidance for the McKinney-Vento program specifying that a local liaison may continue to provide verification of a youth's homelessness status for federal student aid purposes for as long as the liaison has access to the information necessary to make such a determination for a particular youth. The guidance also stated that local homelessness liaisons should ensure that all homeless high school students receive information and counseling on college-related issues. Education said that it will also hold a technical assistance webinar for McKinney-Vento Education for Homeless Children and Youths Program liaisons. In the 2017-18 Application and Verification Guide for financial aid administrators, Education clarified circumstances under which authorized officials may provide documentation of unaccompanied homelessness for a person who is no longer officially receiving services. The updated guide also noted that local homelessness liaisons may write subsequent year letters of verification for unaccompanied homeless youth through age 23 for whom they have the necessary information to write such letters and that this documentation is acceptable for verifying unaccompanied homelessness. The agency should also update the question and answer factsheet on federal student aid for homeless students so that the information on unaccompanied homeless youth determinations is presented consistently in these key documents.
    Recommendation: To enhance access to federal student aid for unaccompanied homeless youth, the Secretary of Education should consider developing a legislative proposal for congressional action to simplify the application process so that once a student has received an initial determination as an unaccompanied homeless youth, the student will not be required to have that status re-verified in subsequent years but attest to their current status on the Free Application for Federal Student Aid, unless a financial aid administrator has conflicting information.

    Agency: Department of Education
    Status: Open

    Comments: In 2017, Education reported that it is continuing its efforts to address the recommendation. In July 2016, Education said that the department had proposed further simplification of the FAFSA in its fiscal year 2017 budget proposal. Education stated that it will also consider the feasibility of a legislative proposal to not require re-verification of homelessness after a student has received an initial determination. Such a legislative proposal would enhance access to federal student aid for unaccompanied homeless youth.
    Recommendation: To simplify program rules for Chafee ETV vouchers and improve access to these vouchers for former foster youth ages 21 and 22, the Secretary of HHS should consider developing a legislative proposal for congressional action to allow foster youth to be eligible for the Chafee ETV voucher until age 23 without also requiring that they start using the voucher before they turn 21.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS's budget request for fiscal year 2018 does not contain a legislative proposal to improve access to Chafee vouchers for former foster youth ages 21 and 22. In July 2016, HHS noted that it had made a proposal for mandatory programs to improve foster youth's access to vouchers for title IV-E Chafee programs in the Administration for Children and Families' fiscal year 2017 budget request. However, the agency explained that the proposal's purpose is to extend eligibility for Chafee Foster Care Independence Program (CFCIP) services to youth up to age 23 in jurisdictions that have extended foster care to age 21. According to HHS, the budgetary proposal does not affect the Chafee Vouchers. A legislative proposal to simplify program rules for Chafee ETV vouchers would support improving access to these vouchers for former foster youth ages 21 and 22.
    Director: Marcia Crosse
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To ensure that FDA can effectively coordinate and integrate its medical product centers' programs and emerging issues, the Secretary of Health and Human Services should direct the Commissioner of FDA to engage in a strategic planning process to identify challenges that cut across the medical product centers and document how it will achieve measurable goals and objectives in these areas.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: On 9/8/16, FDA provided an update on its actions to address this recommendation. FDA concurred with the recommendation and reiterated that it had started a process to identify key crosscutting themes for the medical products centers, which it would then use to develop an overarching strategic planning framework to guide the work of these centers. The agency indicated that it would provide additional updates in fiscal year 2018.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To help provide reasonable assurance that VHA achieves its long-term goal of modernizing its claims processing system, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that the agency develops a sound written plan that includes the following elements: (1) a detailed schedule for when VHA intends to complete development and implementation of each major aspect of its new claims processing system; (2) the estimated costs for implementing each major aspect of the system; and (3) the performance goals, measures, and interim milestones that VHA will use to evaluate progress, hold staff accountable for achieving desired results, and report to stakeholders the agency's progress in modernizing its claims processing system.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: As of June 2017, VHA's Office of Community Care is in the process of consolidating VA's community care programs, and as part of this process it plans to transition to a third party administrator for the purposes of claims processing. While an active procurement is underway, VHA still needs to develop a written plan to fully implement this recommendation. VHA's written plan must include details about the schedule, cost estimates, performance goals, and interim milestones associated with transitioning to a third party administrator for the purposes of processing claims for VA community care.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To enhance oversight of access to mental health care and help ensure that servicemembers have timely access to mental health care, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to establish an access standard for mental health follow-up appointments and regularly monitor data on these appointments.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Cindy Brown Barnes
    Phone: (202) 512-7215

    3 open recommendations
    Recommendation: To strengthen DOL's efforts to ensure employers protect the safety and health of workers at meat and poultry plants, the Secretary of Labor should direct the Assistant Secretary for Occupational Safety and Health, working together with the Commissioner of Labor Statistics as appropriate, to develop and implement a cost-effective method for gathering more complete data on musculoskeletal disorders.

    Agency: Department of Labor
    Status: Open

    Comments: DOL generally agreed with this recommendation and stated that its implementation would make a difference in working conditions in the meat and poultry industry. The agency also noted that resource constraints may make it difficult to implement.
    Recommendation: To develop a better understanding of meat and poultry sanitation workers' injuries and illnesses, the Secretary of Labor should direct the Assistant Secretary for Occupational Safety and Health and the Commissioner of Labor Statistics to study how they could regularly gather data on injury and illness rates among sanitation workers in the meat and poultry industry.

    Agency: Department of Labor
    Status: Open

    Comments: DOL generally agreed with this recommendation and stated that its implementation would make a difference in working conditions in the meat and poultry industry. The agency also noted that resource constraints may make it difficult to implement.
    Recommendation: To develop a better understanding of meat and poultry sanitation workers' injuries and illnesses, the Secretary of Health and Human Services should direct the Director of the Centers for Disease Control and Prevention to have the National Institute for Occupational Safety and Health (NIOSH) conduct a study of the injuries and illnesses these workers experience, including their causes and how they are reported. Given the challenges to gaining access to this population, NIOSH may want to coordinate with the Occupational Safety and Health Administration to develop ways to initiate this study.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with this recommendation and noted the previous difficulties NIOSH has had gaining access to these workplaces and the potential resource commitment involved in conducting such a study. We acknowledge this access challenge and noted in our report that OSHA has negotiated access for NIOSH in other industries, hence the rationale for recommending that NIOSH may want to coordinate with OSHA. The agency reported that it would reach out to stakeholders, such as worker unions, USDA and OSHA, to discuss the range of types of study that could be conducted to provide useful information. GAO will await the progress of this effort and close the recommendation when the agency initiates a study.
    Director: Michelle Sager
    Phone: (202) 512-6806

    2 open recommendations
    Recommendation: To increase the transparency to Congress about the total amount of funds agencies have available in a given year, the Director of the Office of Management and Budget should identify and publicly report the total amount of actual budget authority government-wide that is temporarily sequestered and "pops up," or becomes available again to agencies for obligation in the subsequent fiscal year.

    Agency: Executive Office of the President: Office of Management and Budget
    Status: Open

    Comments: In February 2017, OMB staff told us they will consider additional options for reporting a government-wide total amount of actual budget authority that is temporarily sequestered during preparation of the full 2018 President's Budget.
    Recommendation: To promote further transparency in measuring the federal government's progress against deficit reduction targets required under current law, the Director of the Office of Management of Budget should identify and publicly report the total amount of actual reductions in budget authority government-wide each year as a result of sequestration or the reduction of discretionary spending limits under BBEDCA.

    Agency: Executive Office of the President: Office of Management and Budget
    Status: Open

    Comments: In February 2017, OMB staff maintained their position of disagreement with this recommendation as summarized in our April 2016 report.
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: The Secretary of Health and Human Services should direct the Administrator of CMS to assess the feasibility of updating the agency's study on the effect of VA-provided Medicare-covered services on per capita county Medicare FFS spending rates by obtaining VA utilization and diagnosis data for veterans enrolled in Medicare FFS under its existing data use agreement or by other means as necessary.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In July 2016, the U.S. Department of Health and Human Services (HHS) reiterated its disagreement with our recommendation. HHS stated that the Centers for Medicare & Medicaid Services (CMS) uses Medicare fee-or-service(FFS) spending rates when setting the benchmark, which excludes services provided by Department of Veterans Affairs (VA) facilities. In addition, HHS stated that incorporating VA utilization and diagnosis data into CMS's analysis may not materially improve the analysis and the resulting adjustment. HHS indicated that it will continue to review the need for incorporating additional data or for methodology changes in the future. As we note in the report, only VA's utilization and diagnosis data can account for services provided by and diagnoses made by VA. Depending on the number and mix of services provided by and the diagnoses made by VA, risk-adjusted Medicare FFS spending for veterans may either be higher or lower than it would be if CMS accounted for VA-provided services and diagnoses. Therefore, relying exclusively on Medicare FFS spending to estimate the effect of VA spending on Medicare FFS-enrolled veterans could result in an inaccurate estimate of how VA spending on services for Medicare FFS-enrolled veterans affects per capita county Medicare FFS spending. While there may be challenges associated with incorporating VA utilization and diagnosis data into CMS's analysis, we maintain that CMS should work to do so given the implications that not incorporating the data may have on the accuracy of payment to MA plans.
    Recommendation: If CMS makes an adjustment to the benchmark to account for VA spending on Medicare-covered services, the Secretary of Health and Human Services should direct the Administrator of CMS to assess whether an additional adjustment to MA payments is needed to ensure that payments to MA plans are equitable for veterans and nonveterans.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The Department of Health and Human Services (HHS)has proposed adjusting the benchmark for 2017 to account for the Department of Veterans Affairs (VA) spending on Medicare-covered services. As of July 2016, HHS had not yet completed its assessment of whether an additional adjustment to MA payments is needed to ensure that payment to Medicare Advantage (MA) plans are equitable for veterans and nonveterans. In order to close this recommendation, CMS will need to complete its assessment.
    Director: James Cosgrove
    Phone: (202) 512-7114

    5 open recommendations
    including 1 priority recommendation
    Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments and to improve the accuracy of CMS's calculation of coding intensity, the Administrator should modify that calculation by taking actions such as the following: (1) including only the three most recent pair-years of risk score data for all contracts; (2) standardizing the changes in disease risk scores to account for the expected increase in risk scores for all MA contracts; (3) developing a method of accounting for diagnostic errors not coded by providers, such as requiring that diagnoses added by MA organizations be flagged as supplemental diagnoses in the agency's Encounter Data System to separately calculate coding intensity scores related only to diagnoses that were added through MA organizations' supplemental record review (that is, were not coded by providers); and (4) including MA beneficiaries enrolled in contracts that were renewed from a different contract under the same MA organization during the pair-year period.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should modify CMS's selection of contracts for contract-level RADV audits to focus on those contracts most likely to have high rates of improper payments by taking actions such as the following: (1) selecting more contracts with the highest coding intensity scores; (2) excluding contracts with low coding intensity scores; (3) selecting contracts with high rates of unsupported diagnoses in prior contract-level RADV audits; (4) if a contract with a high rate of unsupported diagnoses is no longer in operation, selecting a contract under the same MA organization that includes the service area of the prior contract; and (5) selecting some contracts with high enrollment that also have either high rates of unsupported diagnoses in prior contract-level RADV audits or high coding intensity scores.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should enhance the timeliness of CMS's contract-level RADV process by taking actions such as the following: (1) closely aligning the time frames in CMS's contract-level RADV audits with those of the national RADV audits the agency uses to estimate the MA improper payment rate; (2) reducing the time between notifying MA organizations of contract audit selection and notifying them about the beneficiaries and diagnoses that will be audited; (3) improving the reliability and performance of the agency's process for transferring medical records from MA organizations, including assessing the feasibility of updating Electronic Submission of Medical Documentation for use in transferring medical records in contract-level RADV audits; and (4) requiring that CMS contract-level RADV auditors complete their medical record reviews within a specific number of days comparable to other medical record review time frames in the Medicare program.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should improve the timeliness of CMS's contract-level RADV appeal process by requiring that reconsideration decisions be rendered within a specified number of days comparable to other medical record review and first-level appeal time frames in the Medicare program.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should ensure that CMS develops specific plans and a timetable for incorporating a RAC in the MA program as mandated by the Patient Protection and Affordable Care Act.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Marcia Crosse
    Phone: (202) 512-7114

    28 open recommendations
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Agriculture should revise existing department policies for managing hazardous biological agents in high-containment laboratories to contain specific requirements for reporting laboratory incidents to senior department officials, including the types of incidents that should be reported, to whom, and when, or direct the Administrator of the Food Safety and Inspection Service to develop agency policies that contain these requirements.

    Agency: Department of Agriculture
    Status: Open

    Comments: In October 2016 USDA reported that its science and safety councils chartered a joint biorisk management policy committee to oversee the revisions of existing policies to include department-wide incident reporting requirements and time frames. USDA also reported that FSIS will collaborate with the department to ensure that FSIS policies comply with USDA reporting requirements. USDA did not provide an anticipated completion date for revising departmental polices.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Agriculture should review and update outdated department policies for managing hazardous biological agents in high-containment laboratories and direct the Administrators of the Animal and Plant Health Inspection Service (APHIS) and Agricultural Research Service to update their policies and, in the case of APHIS, establish a regular review schedule.

    Agency: Department of Agriculture
    Status: Open

    Comments: In October 2016, USDA reported that the science and safety councils' joint biorisk management policy committee will review and update the existing outdated USDA policies. In addition, USDA reported that APHIS will review agency policies for biological laboratories every 3-5 years or sooner, if necessary, and that this schedule will be reflected in USDA policy. USDA did not provide an anticipated completion date for reviewing and updating departmental polices. USDA reported that ARS has finalized its policies for its institutional biological safety committee in April 2016. Once all USDA and component agency policies have been updated and review schedules established, we will close this recommendation.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Agriculture should routinely analyze results of the department's laboratory inspections and incident reports to identify potential trends that may highlight recurring laboratory safety or security issues and share lessons learned with laboratory personnel.

    Agency: Department of Agriculture
    Status: Open

    Comments: In October 2016, USDA reported that the joint biorisk management policy committee will oversee efforts to collect and analyze laboratory inspection and incident reports and share these reports and critical analyses with USDA senior leadership. USDA did not provide an anticipated start date for analyzing reports and sharing analyses with senior departmental officials. USDA stated that the joint biorisk committee also serves as an information-sharing platform across USDA agencies and, as such, is positioned to share lessons learned from analyses of inspection and incident reports with laboratory personnel as necessary. USDA also provided additional information on APHIS, ARS, and FSIS planned or ongoing inspection and incident report analyses.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Agriculture should require routine reporting of the results of department, agency, and select agent laboratory inspections to senior department officials.

    Agency: Department of Agriculture
    Status: Open

    Comments: In October 2016, USDA reported that the joint biorisk management policy committee will oversee efforts to revise existing departmental regulations to include requirements for routine reporting of inspection results to senior USDA officials. USDA did not provide an anticipated completion date for revising existing departmental regulations. USDA also provided additional information on APHIS, ARS, and FSIS planned or ongoing reporting of inspection results or revisions of agency policies to require such reporting.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Agriculture should require routine reporting of incidents at agency laboratories to senior department officials.

    Agency: Department of Agriculture
    Status: Open

    Comments: In October 2016, USDA reported that the joint biorisk management policy committee will oversee efforts to revise existing departmental regulations to include requirements for routine reporting of laboratory incidents to senior USDA officials. USDA did not provide an anticipated completion date for revising existing departmental regulations. USDA also provided additional information on APHIS, ARS, and FSIS planned or ongoing incident reporting or revisions of agency policies to require such reporting.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Defense should revise existing department policies for managing hazardous biological agents in high-containment laboratories to contain specific requirements for inventory control for all of DOD's high-containment laboratories, not just for its select agent-registered laboratories, or direct the Secretaries of the Air Force, Army, and Navy to revise their existing, respective policies to contain these requirements.

    Agency: Department of Defense
    Status: Open

    Comments: In June 2016, DOD noted that its comments on the final report--in which it agreed with all of our findings and recommendations for the department--had not changed. However, DOD did not provide us with an update on its status in implementing these recommendations.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Defense should direct the Secretaries of the Air Force and Army to review and update their respective outdated policies for managing hazardous biological agents in high-containment laboratories.

    Agency: Department of Defense
    Status: Open

    Comments: In June 2016, DOD noted that its comments on the final report--in which it agreed with all of our findings and recommendations for the department--had not changed. However, DOD did not provide us with an update on its status in implementing these recommendations.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Defense should routinely analyze agencies' inspection results and incident reports to identify potential trends that may highlight recurring laboratory safety or security issues and share lessons learned with laboratory personnel, or direct the Secretaries of the Army and Navy to do so.

    Agency: Department of Defense
    Status: Open

    Comments: In June 2016, DOD noted that its comments on the final report--in which it agreed with all of our findings and recommendations for the department--had not changed. However, DOD did not provide us with an update on its status in implementing these recommendations.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Defense should require routine reporting of the results of Air Force, Army, and Navy inspections of non-select agent registered laboratories to senior department officials.

    Agency: Department of Defense
    Status: Open

    Comments: In June 2016, DOD noted that its comments on the final report--in which it agreed with all of our findings and recommendations for the department--had not changed. However, DOD did not provide us with an update on its status in implementing these recommendations.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Defense should require routine reporting of laboratory incidents at Air Force, Army, and Navy non-select agent registered laboratories to senior department officials.

    Agency: Department of Defense
    Status: Open

    Comments: In June 2016, DOD noted that its comments on the final report--in which it agreed with all of our findings and recommendations for the department--had not changed. However, DOD did not provide us with an update on its status in implementing these recommendations.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Defense should direct the Secretaries of the Army and Navy to require reporting of agency and select agent laboratory inspection results to senior agency officials.

    Agency: Department of Defense
    Status: Open

    Comments: In June 2016, DOD noted that its comments on the final report--in which it agreed with all of our findings and recommendations for the department--had not changed. However, DOD did not provide us with an update on its status in implementing these recommendations.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Defense should develop time frames for the 19 specific recommendations from the July 2015 review, or direct the Secretary of the Army to do so.

    Agency: Department of Defense
    Status: Open

    Comments: In June 2016, DOD noted that its comments on the final report--in which it agreed with all of our findings and recommendations for the department--had not changed. However, DOD did not provide us with an update on its status in implementing these recommendations.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Energy should revise existing department policies for managing hazardous biological agents in high-containment laboratories to contain specific requirements for inspections, or direct the Administrator of the National Nuclear Security Administration and the Director of the Office of Science to develop agency policies that contain this requirement.

    Agency: Department of Energy
    Status: Open

    Comments: In August 2016, DOE reported that it is revising department policy for its select agent and toxin work to highlight oversight of facilities working with these agents and toxins. DOE will solicit input from NNSA, the Office of Science, and its biosurety executive team to determine if specific inspection requirements should be included in the select agent, or other department or agency policies. DOE provided us with information as to other department policies and regulations that allow for inspections. DOE plans to complete its efforts by the end of July 2017. We maintain that DOE should make laboratory inspection requirements explicit and that these requirements apply to all high-containment laboratories, not just those registered with the select agent program.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Energy should review and update its outdated policies for managing hazardous biological agents in high-containment laboratories.

    Agency: Department of Energy
    Status: Open

    Comments: In August 2016, DOE reported that it is updating its outdated select agent policy and plans to complete this update by the end of July 2017.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Administrator of the Environmental Protection Agency (EPA) should revise existing EPA policies for managing hazardous biological agents in high-containment laboratories to contain specific requirements for inventory control, or direct the Director of the Office of Pesticide Programs to incorporate this requirement into its policy.

    Agency: Environmental Protection Agency
    Status: Open

    Comments: EPA agreed with this recommendation in its February 2016 comments on the draft report, but maintains that agency, or senior-level policies, exist that include this requirement. EPA officials cited a Microbiology Laboratory Branch standard operating procedure (SOP) as containing inventory control requirements for the agency's one high-containment laboratory. However, in July 2016, EPA officials told us that it disagreed with our assessment that the SOP, as a laboratory-level document, was insufficient to meet our expectations for senior-level policies. In November 2016, EPA officials reiterated its position stating that the SOP had been approved by senior agency management and, as the requirements in it are universally applied by all laboratory staff, appropriately represents an agency-level policy. EPA further noted that the Office of Pesticide Policy, in which the Microbiology Laboratory Branch is located, is a sub-office within EPA's Office of Chemical Safety and Pollution Prevention (OCSPP), an Assistant Administrator-level office. We continue to believe that senior-level policies--in this case, either those policies issued at the EPA level or at the OCSPP/OPP level--that include all of the policy elements we analyzed reflect critical management commitment to and support for a culture of laboratory safety throughout the organization, regardless of the number of agency laboratories.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Administrator of EPA should review and update EPA's outdated policies for managing hazardous biological agents in high-containment laboratories and establish a regular schedule for reviewing and updating EPA and Office of Pesticide Programs policies.

    Agency: Environmental Protection Agency
    Status: Open

    Comments: In July 2016, EPA reported that the policies and procedures for both the facility that houses its microbiology laboratory and the laboratory itself are reviewed and updated on a bi-yearly or yearly basis consistent with the EPA schedules for biosafety and laboratory plans set in policy. However, EPA did not provide us with the policy that sets the EPA schedules. In addition, our analysis focused on policy documents issued by EPA or its senior-level offices, such as EPA's Safety, Health, and Environmental Management Program manual, dated November 2012. When we analyzed that policy for the report, we were unable to determine whether it was up-to-date because it did not include a review and update schedule or a specific recertification date. As of November, 2016, EPA maintains that this recommendation has been completed, because the office revised the standard operating procedure that provides guidance for establishing the receipt, expiration dates, and disposal of biological inventory used in the laboratory. As of April 2017, we have reached out to EPA for documentation of the actions the agency stated it has taken. Until received, we continue to believe that EPA action on this recommendation is still needed, such as by providing an updated EPA-level safety manual that includes a schedule for reviewing and updating, or providing EPA's schedule set in policy, so long as it also applies to agency- or senior office-level policies.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Administrator of EPA should require routine reporting of the results of department, agency, and select agent laboratory inspections to senior department officials.

    Agency: Environmental Protection Agency
    Status: Open

    Comments: EPA agreed with this recommendation in its February 2016 comments on the draft report. ?In July 2016, EPA reported that its high-containment laboratory will notify senior officials within 3 weeks of any laboratory inspection findings. ?This is a positive step. We are waiting for EPA to provide us with supporting documentation.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Health and Human Services should develop department policies for managing hazardous biological agents in high-containment laboratories that contain specific requirements for reporting laboratory incidents to senior department officials, including the types of incidents that should be reported, to whom, and when, or direct the Director of CDC and the Commissioner of FDA to incorporate these requirements into their respective policies.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In August 2016, HHS reported that both CDC and FDA were working to incorporate incident reporting requirements and time frames into formal agency policies and practices but did not provide an anticipated completion date. In summer 2017, CDC and FDA reported that they were continuing to incorporate incident reporting, which includes all laboratory incidents, accidents, injuries, infections, and near-misses, into formal agency policies. CDC did not provide an anticipated completion date. FDA anticipated completing the policy revisions/updates by summer 2018.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Health and Human Services should develop department policies for managing hazardous biological agents in high-containment laboratories that contain specific requirements for training and inspections for all high-containment component agency laboratories and not just for their select-agent-registered laboratories; or direct the Director of CDC to provide these requirements in agency policies.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In August 2016, HHS reported that CDC plans to revise its policies to include training and inspection requirements for inspections for all high-containment laboratories but did not provide an anticipated completion date. In June 2017, HHS reported that CDC was in the process of revising its formal policies to ensure they included requirements for training and inspections for all of the agency's high-containment laboratories but did not provide an anticipated completion date.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Health and Human Services should require routine reporting of the results of agency and select agent laboratory inspections to senior department officials.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In August 2016, HHS reported that CDC was working with FDA and NIH to establish a process for notifying HHS leadership of inspection results through the department's Biosafety and Biosecurity Coordinating Council. HHS did not provide us with an anticipated time frame for implementing this notification practice or when the agencies plan to begin notifying HHS of inspection results.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Health and Human Services should direct the Director of NIH and the Commissioner of FDA to require routine reporting of the results of agency laboratory inspections--and in the case of FDA, require routine reporting of select agent inspection results--to senior agency officials.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In August 2016, HHS reported that FDA is working to establish a process for notifying senior agency officials of inspection results, and in August 2017, FDA reported that it was in the process of updating its policies to reflect such a notification process. FDA anticipated that the updated policies and processes would be in place by summer 2018. In August 2016, HHS reported that NIH's ongoing practice is to report the results of external inspections to senior agency officials and, in May 2016, developed a standard operating procedure that outlines this reporting process. In March 2017, NIH officials provided assurance that its Division of Occupational Safety and Health provides NIH's intramural governing body with information about NIH's safety performance at least annually; officials further assured that this information includes the overall results of annual inspections (or audits, as NIH calls them) of all NIH laboratories and discussion of the top 10 most report safety infractions for the year. GAO considers NIH to have implemented the recommended action. GAO will close the overall recommendation once FDA has taken equivalent, appropriate action.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Health and Human Services should require routine reporting of incidents at CDC, FDA, and NIH laboratories to senior department officials.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In August 2016, HHS reported that its Biosafety and Biosecurity Council is working to establish incident reporting requirements for CDC, FDA, and NIH but did not provide an anticipated completion date. HHS noted that NIH formally adopted a standard operating procedure that lays out the agency's requirements for reporting incidents to senior officials.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of the Interior should develop department policies, or direct the Directors of Fish and Wildlife Service and U.S. Geological Survey to develop agency policies for managing hazardous biological agents in high-containment laboratories that contain specific requirements for reporting laboratory incidents to senior department officials--including the types of incidents that should be reported, to whom, and when--and specific requirements for roles and responsibilities, training, inventory control, and inspections.

    Agency: Department of the Interior
    Status: Open

    Comments: In July 2016, DOI reported that the Fish and Wildlife Service and U.S. Geological Survey will develop agency-level policies that contain the key elements GAO identified. DOI did not provide us with a time frame for these activities.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of the Interior should routinely analyze the results of the agency's laboratory inspections and incident reports to identify potential trends that may highlight recurring laboratory safety or security issues and share lessons learned with laboratory personnel, or direct the Directors of Fish and Wildlife Service and U.S. Geological Survey to do so.

    Agency: Department of the Interior
    Status: Open

    Comments: In July 2016, DOI reported that its Biosafety Working Group, composed of officials across the department, including Fish and Wildlife Service and U. S. Geological Survey, is developing an automated process for analyzing results of laboratory inspections and incident reports to identify safety and security trends. The working group is also developing a process to share information gleaned from these analyses, including lessons learned, with laboratory personnel in a timely manner. DOI did not provide us with a time frame for these activities.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of the Interior should require routine reporting of the results of agency and select agent inspections to senior department officials.

    Agency: Department of the Interior
    Status: Open

    Comments: In July 2016, DOI reported that in according with the reporting requirements it plans to incorporate into agency-level policies in response to our first recommendation, Fish and Wildlife Service and U. S. Geological survey will be required to submit routine or periodic reports of the results of agency and select agent inspections to the department's designated agency safety and health official.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of the Interior should direct the Director of the U.S. Geological Survey to require routine reporting of the results of agency and select agent laboratory inspections to senior agency officials.

    Agency: Department of the Interior
    Status: Open

    Comments: In July 2016, DOI reported that the U. S. Geological Survey will modify and expand its existing policies to require reporting of agency and select agent inspection results to senior USGS officials.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Veterans Affairs should develop department policies for managing hazardous biological agents in high-containment laboratories that contain specific requirements for reporting laboratory incidents to senior department officials--including the types of incidents that should be reported, to whom, and when--and requirements for inventory control for all of its high-containment laboratories, including its select agent-registered clinical laboratory, or direct the Under Secretary of Health to incorporate these requirements into its policies.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: In June 2016, VA reported that while it has policies for reporting laboratory incidents at the local level (VA medical center or laboratory level), VA plans to develop a national level policy for reporting laboratory incidents to senior department officials, including the types of incidents to report, to whom, and when. VA will convene a task force for the purposes of developing such a policy and anticipates that the task force will finalize its policy by March 2018. In June 2017, VA reported that the task force concluded that VA's existing emergency management plan contained all of the necessary requirements for laboratory incident reporting. However, VA has not provided GAO with the emergency management plan. VA further noted that a intradepartmental memorandum was sufficient for making employees aware of such policy requirements in the emergency plan and that such a memorandum was drafted and was being processed for dissemination throughout VA, with an anticipated completion date of August 2017.
    Recommendation: To ensure that federal departments and agencies have comprehensive and up-to-date policies and stronger oversight mechanisms in place for managing hazardous biological agents in high-containment laboratories and are fully addressing weaknesses identified after laboratory safety lapses, the Secretary of Veterans Affairs should direct the Under Secretary of Health to review and update outdated agency policies for managing hazardous biological agents in high-containment laboratories.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA updated and finalized its outdated policy for its clinical laboratories in February 2016. In July 2016, VA reported that it has begun updating its policies for its research laboratories and anticipated finalizing them in 6 months. In June 2017, VA reported that its policies for its research laboratories remain under review and revision, with an anticipated completion date of December 2017.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. This could be accomplished, for example, by building on the data collection efforts currently being implemented under the "Welcome to VA" program.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: In March 2016, GAO recommended that VA monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. VA concurred with this recommendation, and in June 2017, reported to GAO that it had taken actions to address this recommendation. Specifically, VA indicated that it revised an internal report to help identify and document all newly enrolled veterans and monitor their appointment request status. The report is intended to enable VHA and its medical centers to oversee the enrollment and appointment process by tracking the following timeframes: (1) application to enrollment, (2) enrollment to initial contact, (3) initial contact to primary care appointment, and (4) total time from application from appointment. However, VA also indicated in its response that it does not have data that captures application dates for all newly enrolled veterans. As a result, this report cannot be used to consistently monitor the full amount of time these veterans wait to be seen by primary care providers. To fully implement this recommendation VA needs to capture the application date for all newly enrolled veterans. Upon receiving further information about how and when VA plans to capture this information, we will assess whether VA's actions are sufficient to warrant closure of this recommendation.
    Director: Linda Kohn
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To enhance its stewardship of clinical trials across the ICs, the Secretary of the Department of Health and Human Services (HHS) should direct the NIH OD to finalize data on clinical trial activity that the OD needs to collect from ICs.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with this recommendation and stated that the agency plans to complete its efforts to identify additional data that will be collected from the ICs on a regular basis. HHS indicated that these data will provide the OD with readily available information on the number, type, and progress of clinical trials funded across the ICs. HHS stated that a working group of NIH staff with expertise in clinical trials has been assembled to begin developing specific requirements for the enterprise-wide system for clinical trial management and oversight.
    Recommendation: To enhance its stewardship of clinical trials across the ICs, the Secretary of HHS should direct the NIH OD to establish and implement a process for using those data.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with this recommendation and stated that the agency plans to complete its efforts to identify additional data that will be collected from the ICs on a regular basis. HHS indicated that these data will provide the OD with readily available information on the number, type, and progress of clinical trials funded across the ICs. HHS stated that a working group of NIH staff with expertise in clinical trials has been assembled to begin developing specific requirements for the enterprise-wide system for clinical trial management and oversight, and that the system will be used by NIH OD and the NIH ICs to meet stewardship responsibilities and for strategic planning and priority setting.
    Director: Rebecca Gambler
    Phone: (202) 512-8777

    1 open recommendations
    Recommendation: 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.

    Agency: Department of Homeland Security
    Status: Open

    Comments: As of May 2017, ICE has not provided a status update regarding the implementation of this recommendation. We will provide updated information after confirming any agency actions.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    6 open recommendations
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to perform data-driven strategic workforce planning prior to implementing any future integration efforts.

    Agency: Department of Defense
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to perform data-driven strategic workforce planning prior to implementing any future integration efforts.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to determine how best to fill the FHCC's short-term staffing needs, including any additional statutory authorities that might be necessary to implement the desired approach.

    Agency: Department of Defense
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to determine how best to fill the FHCC's short-term staffing needs, including any additional statutory authorities that might be necessary to implement the desired approach.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to resolve differences in IT network security standards to the extent possible prior to implementing any future integration efforts.

    Agency: Department of Defense
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to resolve differences in IT network security standards to the extent possible prior to implementing any future integration efforts.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Director: Seto J. Bagdoyan
    Phone: (202) 512-6722

    8 open recommendations
    including 8 priority recommendations
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to conduct a comprehensive feasibility study on actions that CMS can take to monitor and analyze, both quantitatively and qualitatively, the extent to which data hub queries provide requested or relevant applicant verification information, for the purpose of improving the data-matching process and reducing the number of applicant inconsistencies; and for those actions identified as feasible, create a written plan and schedule for implementing them.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported that it considered this recommendation open and it was reviewing options for conducting a feasibility study to monitor and analyze information received from the Hub as recommended. HHS plans to examine the hub process in delivering usable information for applicant verification and analyzing data to identify trends or patterns that could suggest improvements in verification or actions that could reduce the number of inconsistencies that require further attention. HHS reported that this effort began March 2016. In March 2017, the agency said it is making significant progress towards implementing the recommendation. We will continue to monitor HHS's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to track the value of advance premium tax credit and cost-sharing reduction (CSR) subsidies that are terminated or adjusted for failure to resolve application inconsistencies, and use this information to inform assessments of program risk and performance. (See related recommendation 7.)

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported it considers this recommendation closed because it expanded the use of analytics to analyze the value of premium tax credit and CSR subsidies that are eliminated or adjusted for 2015 actions at the policy level, and that CMS continues to analyze the data to develop future operations changes. In May 2016, we requested documentation of these actions, including (1) information produced using the capability described; (2) ways in which this information is being used for analysis for purposes such as program operations, monitoring, risk assessment, or fraud cleaning; and (3) a description of the future operational changes contemplated based on the analyses done. Once received, we will review to determine whether the efforts taken warrant closing the recommendation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to, in the case of CSR subsidies that are terminated or adjusted for failure to resolve application inconsistencies, consider and document, in conjunction with other agencies as relevant, whether it would be feasible to create a mechanism to recapture those costs, including whether additional statutory authority would be required to do so; and for actions determined to be feasible and reasonable, create a written plan and schedule for implementing them.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported it considers this recommendation closed because CMS has considered whether it would be feasible to create a mechanism to recapture CSRs and determined that this is not possible under the current statute. HHS also noted that as currently written, the statute does not provide this authority and to pursue developing a mechanism to do so would require Congress to change the statute. In May 2016, we agreed to consider the recommendation closed upon HHS advising us if it made any review or inquiry into the feasibility of recapture apart from statutory authority and providing documentation of such consideration so that we have a full record of the agency's consideration prior to closing the recommendation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to identify and implement procedures to resolve Social Security number inconsistencies where the Marketplace is unable to verify Social Security numbers or applicants do not provide them.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported that it considered this recommendation open and was working on implementing functionality for updating consumers' Social Security numbers (SSN) and their eligibility based on the correct SSN. HHS reported that is it targeting deployment of the SSN update functionality in 2017. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to reevaluate CMS's use of Prisoner Update Processing System (PUPS) incarceration data and make a determination to either (a) use the PUPS data, among other things, as an indicator of further research required in individual cases, and to develop an effective process to clear incarceration inconsistencies or terminate coverage, or (b) if no suitable process can be identified to verify incarceration status, accept applicant attestation on status in all cases, unless the attestation is not reasonably compatible with other information that may indicate incarceration, and forego the inconsistency process.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported it considers this recommendation closed because in 2015, it made the determination to no longer require application filers to submit documentation regarding incarceration status. We were aware of that determination, but the recommendation was to reevaluate use of PUPS from the specific standpoint of using the data as it was intended to be used as in indicator of further research and then draw a conclusion on the use of the data. In May 2016, we requested documentation demonstrating that in the period since we made this recommendation, CMS has undertaken the reevaluation in the fashion that we indicated. Once received, we will review to determine whether the efforts taken warrant closing the recommendation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to create a written plan and schedule for providing Marketplace call center representatives with access to information on the current status of eligibility documents submitted to CMS's documents processing contractor.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported it considers this recommendation closed because since May 2015, call center representatives have received daily updates on the status of eligibility documentation. It is working to provide call center representatives with real-time data that is tentatively scheduled for later in 2016. In May 2016, we noted that our recommendation was focused on providing such real-time capability and requested (1) confirmation that call center representatives currently have on-demand, real-time access to up-to-date, application-level document status; and documentation showing development and implementation of this capability; or (2) a written plan and schedule for providing this capability as recommended. Once received, we will review to determine whether the efforts taken warrant closing the recommendation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to conduct a fraud risk assessment, consistent with best practices provided in GAO's framework for managing fraud risks in federal programs, of the potential for fraud in the process of applying for qualified health plans through the federal Marketplace.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported that it considered this recommendation open. It noted that CMS has launched a Marketplace Integrated Project Team (IPT) through the Program Integrity Board, which includes senior staff from across CMS. An objective of the IPT is to complete the fraud risk assessment of Marketplace eligibility and enrollment based on GAO's Fraud Risk Framework, as required by the recommendation. HHS said the first three steps of GAO's framework for this part were to be completed by early summer. Once HHS has completed all relevant steps of the framework, and the agency has fully documented its implementation efforts-including discussion of any items contemplated by the framework that HHS elected not to follow-we will review to determine whether the efforts taken warrant closing the recommendation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to fully document prior to implementation, and have readily available for inspection thereafter, any significant decision on qualified health plan enrollment and eligibility matters, with such documentation to include details such as policy objectives, supporting analysis, scope, and expected costs and effects.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported it considers this recommendation closed because CMS prepares an annual Marketplace and Related Programs Cycle Memo to fulfill reporting requirements for internal control. The Memo describes all significant eligibility and enrollment policy and process changes, including new internal key controls associated with these changes, and the 2015 Memo was released in September 2015. In May 2016, we notified HHS that its actions do not close the recommendation. Information contained in the Memos is after-the-fact and while useful, does not meet the full range of documentation contemplated by our recommendation, especially development and analysis of changes prior to implementation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Director: Timothy J. DiNapoli
    Phone: (202) 512-4841

    4 open recommendations
    including 3 priority recommendations
    Recommendation: Given that the intent of section 235 of Title 10 United States Code was to provide both DOD and Congress with increased oversight of the procurement of services, Congress should consider revising the section to require that DOD report on its projected spending beyond the budget year and consistent with the time period covered by the future year defense program.

    Agency: Congress
    Status: Open

    Comments: Congress has not revised section 235 of Title 10 United States Code. GAO will continue to monitor this matter for Congressional consideration.
    Recommendation: To ensure that senior leadership within the Office of the Secretary of Defense and the military departments are better positioned to make informed decisions regarding the volume and type of services that should be acquired over the future year defense program, the Secretaries of the Army, Navy, and Air Force should revise their programming guidance to collect information on how contracted services will be used to meet requirements beyond the budget year.

    Agency: Department of Defense: Department of the Air Force
    Status: Open
    Priority recommendation

    Comments: As of July 2017, DOD staff from the programming and budgeting communities have initiated discussions on how to improve consideration of services beyond the budget year. The Air Force, however, has not identified any specific steps to modify their programming guidance.
    Recommendation: To ensure that senior leadership within the Office of the Secretary of Defense and the military departments are better positioned to make informed decisions regarding the volume and type of services that should be acquired over the future year defense program, the Secretaries of the Army, Navy, and Air Force should revise their programming guidance to collect information on how contracted services will be used to meet requirements beyond the budget year.

    Agency: Department of Defense: Department of the Navy
    Status: Open
    Priority recommendation

    Comments: As of July 2017, DOD staff from the programming and budgeting communities have initiated discussions on how to improve consideration of services beyond the budget year. The Air Force, however, has not identified any specific steps to modify their programming guidance.
    Recommendation: To ensure the military departments' efforts to integrate services into the programming process and senior service managers efforts to develop forecasts on service contract spending provide the department with consistent data, the Secretary of Defense should establish a mechanism, such as a working group of key stakeholders--which could include officials from the programming, budgeting and requirements communities as well as the senior services managers--to coordinate these efforts.

    Agency: Department of Defense
    Status: Open
    Priority recommendation

    Comments: As of July 2017, DOD has not taken specific action(s) to address the recommendation. We will continue to monitor this recommendation.
    Director: Steve D. Morris
    Phone: (202) 512-3841

    6 open recommendations
    Recommendation: To improve the effectiveness of federal efforts to monitor wild, native bee populations, the Secretary of Agriculture, as a co-chair of the White House Pollinator Health Task Force, should coordinate with other Task Force agencies that have monitoring responsibilities to develop a mechanism, such as a federal monitoring plan, that would (1) establish roles and responsibilities of lead and support agencies, (2) establish shared outcomes and goals, and (3) obtain input from relevant stakeholders, such as states.

    Agency: Department of Agriculture
    Status: Open

    Comments: As of August 2017, USDA had taken relevant and positive actions but had not yet fully implemented the recommendation related to monitoring wild, native bees. In June 2017, USDA held a stakeholder listening session to gather input to prepare for the development of a monitoring plan. Prior to that, in February 2017, USDA chaired a meeting with representatives from USDA and Interior to discuss how to proceed in replying to the native bee monitoring recommendation. According to a senior USDA official, the meeting participants agreed to form a team to address the recommendation. The participants also planned future relevant activities. These included plans to (1) hold a stakeholder listening session in June 2017 to determine what will be needed to conduct a robust native bee survey, including the identification of any non-Federal entities that might be able to contribute to a native bee monitoring initiative; (2) develop a prospectus in August 2017 that will be shared with all the agencies represented on the Pollinator Health Task Force to ensure minimal duplication of effort and to capitalize on any other activities; (3) hold a December 2017 workshop of stakeholders and scientists to write a white paper on how to combine Federal resources to address the need for a native bee survey; (4) develop the white paper in February 2018 with information on the status of monitoring efforts, current and future needs for effective and comprehensive monitoring, and the status of monitoring partnerships between Federal agencies, State agencies, and nongovernmental organizations; (5) continue bi-weekly conference calls with task teams to address what can be done with current resources; and (6)complete a gaps analysis in May 2018 to determine how to allocate additional resources.
    Recommendation: To increase the accessibility and availability of information about USDA-funded research and outreach on bees, the Secretary of Agriculture should update the categories of bees in the Current Research Information System to reflect the categories of bees identified in the White House Pollinator Health Task Force's research action plan.

    Agency: Department of Agriculture
    Status: Open

    Comments: In March 2017, the agency informed GAO that it planned to complete the recommendation by October 2017.
    Recommendation: To better ensure the effectiveness of USDA's bee habitat conservation efforts, the Secretary of Agriculture should direct the Administrators of FSA and NRCS to, within available resources, increase evaluation of the effectiveness of their efforts to restore and enhance bee habitat plantings across the nation, including identifying gaps in expertise and technical assistance funding available to field offices.

    Agency: Department of Agriculture
    Status: Open

    Comments: As of August 2017, the agency had not acted on our recommendation.
    Recommendation: To better ensure that EPA is reducing the risk of unreasonable harm to important pollinators, the Administrator of EPA should direct the Office of Pesticide Programs to develop a plan for obtaining data from pesticide registrants on the effects of pesticides on nonhoney bee species, including other managed or wild, native bees.

    Agency: Environmental Protection Agency
    Status: Open

    Comments: As of May 2017, the agency had taken actions relevant to the recommendation but had not fully developed a plan to obtain data from pesticide registrants on the effects of pesticides on non-honey bee species. According to EPA, until suitable test methods have been developed, the agency has continued to rely on honey bees as a surrogate for the broader range of bee species that include both solitary and social non-honey bees. The agency continues to track the Organization for Economic Cooperation and Development's (OECD's) efforts to develop suitable test methods to evaluate the effects of pesticides on non-honey bees. EPA provided comments to the OECD on the acute oral and acute contact toxicity test guidelines developed for bumble bees, which are social non-honey bee managed bees; these test methods were recently finalized by OECD as formal test guidelines. Also, EPA staff serve as members of the International Commission on Plant-Pollinator Relationship (ICP-PR), for which a non-honey bee workgroup has been developing acute and chronic toxicity test methods for other managed non-honey bees, including the solitary mason bee. EPA researchers in the National Health and Environmental Effects Research Laboratory (within the Office of Research and Development) are developing methods for measuring effects of pesticides on bumble bee colonies through the use of micro-colonies, and will be participating in field studies over the next two years to determine the effectiveness of these methods in evaluating impacts to bumble bees from the use of pesticides used in horticulture. According to the agency, once sufficient data are available, EPA will be in a better position to determine the extent to which honey bees serve as reasonable surrogates for estimating the sensitivity of non-honey bees to pesticides. According to agency officials, EPA included the recent OECD acute contact and acute oral toxicity tests with bumble bees with the suite of laboratory and semi-field studies in a rulemaking effort that would codify these tests as formal data requirements for registrants. EPA had planned to solicit public comment on the proposed bumble bee testing requirements; however, the rulemaking effort has been delayed until the regulatory burden of the rule can be more thoroughly evaluated. According to agency officials, in January 2017, EPA hosted an international workshop on non-honey bees to evaluate the extent to which the primary routes of exposure for honey bees (i.e., contact and ingestion of residues in pollen/nectar) are protective and serve as suitable surrogates for evaluating exposure of non-honey bees to pesticides. Workshop participants discussed data needed to evaluate exposure for solitary and social non-honey bees. The proceedings of this workshop will be published in a peer-reviewed journal, and will inform EPA's understanding of whether additional routes of exposure need to be considered as part of EPA's risk assessment framework for pollinators. While these are positive developments, they do not constitute full implementation of the recommendation.
    Recommendation: To help comply with the directive in the White House Pollinator Health Task Force's strategy, the Administrator of EPA should direct the Office of Pesticide Programs to identify the pesticide tank mixtures that farmers and pesticide applicators most commonly use on agricultural crops to help determine whether those mixtures pose greater risks than the sum of the risks posed by the individual pesticides.

    Agency: Environmental Protection Agency
    Status: Open

    Comments: As of May 2017, EPA had taken actions relevant to this recommendation but had not fully implemented it. According to EPA, during February and March 2017, the Office of Pesticide Programs continued its efforts to monitor residues in honey bee colonies providing pollination services in almond orchards. In April 2017, EPA requested that the California Department of Pesticide Regulation provide Pesticide Use Reporting data, including specific formulation and quantities applied to specific sites on specific dates during almond bloom. EPA has also reached out to the Almond Board, as well as to beekeepers and almond growers, to request information on the most common tank mixes applied during almond bloom. Although EPA has previously requested Pesticide Use Reporting data from California and the state has provided preliminary data, the information was not sufficiently detailed to extract actual formulations applied on specific dates to specific areas within the almond growing region of California. The combination of information requested from the California Department of Pesticide Regulation and the Almond Board is expected to provide data to evaluate and identify commonly used pesticide tank mixes applied during almond pollination as a case study. According to EPA officials, data from California indicate that the use of tank mixtures in almond orchards decreased by roughly 60 percent from 2014 through 2016, suggesting that best management practices recommended by the Almond Board may be having a positive effect on almond grower practices with respect to tank mixtures. While these are positive developments, they do not yet fully implement the recommendation. It is not yet clear that EPA has used information on the identity of the most common tank mixtures to determine whether they pose greater risks than the sum of the risks posed by the individual pesticides. In addition, it is not yet clear that EPA has identified tank mixtures commonly used on crops other than almonds.
    Recommendation: To measure their contribution to the White House Pollinator Health Task Force strategy's goal to restore and enhance 7 million acres of pollinator habitat, the Secretary of Agriculture should direct the Administrators of the Farm Service Agency (FSA) and the Natural Resources Conservation Service (NRCS) to develop an improved method, within available resources, to track conservation program acres that contribute to the goal.

    Agency: Department of Agriculture
    Status: Open

    Comments: As of March 2017, USDA had not acted on this recommendation.
    Director: Carolyn L. Yocom
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To ensure states have appropriate and current guidance to assist them in designing and administering Medicaid NEMT, the Secretary of HHS should direct CMS to assess current Medicaid NEMT guidance and update that guidance as needed.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Debra Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: The Secretary of Defense should direct the Secretary of the Army to implement processes to review and monitor the Army military treatment facility prescribing practices for medications discouraged under the PTSD guideline and address identified deviations.

    Agency: Department of Defense
    Status: Open

    Comments: We requested an update on the status of this recommendation. As of June 21, 2016, we are waiting for a response from DOD.
    Director: Kathleen M. King
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To strengthen oversight of the provision of care coordination services in the Financial Alignment Demonstration, the Secretary of Health and Human Services should direct the Administrator of CMS to expediently develop and require organizations in the capitated model, and the states in the MFFS model, to report comparable core data measures across the demonstration that measure the following: (1) the extent to which interdisciplinary care team meetings are occurring, and (2) for MFFS states, the extent to which health risk assessments are completed.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In April 2016, CMS officials told us they are exploring whether it would be feasible to identify and develop additional measures related to interdisciplinary care team meetings and health risk assessment completion within the demonstration period. For the first part of our recommendation, CMS officials said that they did not believe it was feasible to implement a care team measure during the demonstration period. For the second part of our recommendation, CMS officials said they had begun discussions with their existing CMS contractor about the level of effort required to develop and implement a health risk assessment measure in the Managed-Fee-For-Service (MFFS) demonstrations. CMS also planned to have discussions with the MFFS model states about the feasibility of collecting and reporting this type of data. As of June 2017, HHS officials have not informed us of any actions taken to implement this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: To strengthen oversight of the provision of care coordination services in the Financial Alignment Demonstration, the Secretary of Health and Human Services should direct the Administrator of CMS to align CMS's existing state-specific measures regarding the extent to which individualized care plans are being developed across the capitated and MFFS states to make them comparable and designate them as a core reporting requirement.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In April 2016, CMS officials said they planned to use an existing CMS contractor to develop a care plan measure that more closely aligns the specifications across demonstrations. As of June 2017, HHS officials have not informed us of any actions taken to implement this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Kathleen M. King
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To ensure that HHS workforce efforts meet national needs, the Secretary of Health and Human Services should develop a comprehensive and coordinated planning approach to guide HHS's health care workforce development programs--including education, training, and payment programs--that (1) includes performance measures to more clearly determine the extent to which these programs are meeting the department's strategic goal of strengthening health care; (2) identifies and communicates to stakeholders any gaps between existing programs and future health care workforce needs identified in the Health Resources and Services Administration's workforce projection reports; (3) identifies actions needed to address identified gaps; and (4) identifies and communicates to Congress the legislative authority, if any, the Department needs to implement the identified actions.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In December 2016, HHS indicated that the agency had not yet taken steps to implement a comprehensive workforce planning effort. Officials said that for the FY2018 cycle, HHS had planned to expand its group developing legislative proposals to include budget issues and gaps that warrant attention. While it did not do so during that cycle, officials indicated that they would recommend this broader approach to workforce planning for future budget and legislative cycles.
    Director: Gregory C. Wilshusen
    Phone: (202) 512-6244

    7 open recommendations
    Recommendation: To better monitor and provide a basis for improving the effectiveness of cybersecurity risk mitigation activities, informed by the sectors' updated plans and in collaboration with sector stakeholders, the Secretary of Homeland Security should direct responsible officials to develop performance metrics to provide data and determine how to overcome challenges to monitoring the chemical, commercial facilities, communications, critical manufacturing, dams, emergency services, information technology, and nuclear sectors' cybersecurity progress.

    Agency: Department of Homeland Security
    Status: Open

    Comments: DHS has released updated sector-specific plans for the chemical, commercial facilities, communications, critical manufacturing, dams, emergency services, information technology, and nuclear reactors sectors. The plans include a section on measuring effectiveness based on the plan development guidance. The plans provide expected metrics to track the progress of sector activities and state that the outcomes will be reported through the National Annual Reporting process as well as through the quadrennial plan update. Because the metrics are new and annual reporting has not yet occurred, DHS has not provided evidence of metrics data collected and reported to address the challenges. We will continue to follow-up to determine how performance measures have been implemented and what reporting is available based on those measures.
    Recommendation: To better monitor and provide a basis for improving the effectiveness of cybersecurity risk mitigation activities, informed by the sectors' updated plans and in collaboration with sector stakeholders, the Secretary of the Treasury should direct responsible officials to develop performance metrics to provide data and determine how to overcome challenges to monitoring the financial services sector's cybersecurity progress.

    Agency: Department of the Treasury
    Status: Open

    Comments: The 2015 sector-specific plan for the financial services sector includes a section on measuring the effectiveness of sector activities; however, the plan does not include specific metrics. The plan refers to working groups and meetings of sector stakeholders as mechanisms to track sector progress. No specific metrics and associated reports of outcomes have been provided to address overcoming the challenges of monitoring the sector's cybersecurity progress. We will continue to monitor financial services sector activities and determine any specific metrics and related reports developed and implemented to track and report on the sector's cybersecurity progress.
    Recommendation: To better monitor and provide a basis for improving the effectiveness of cybersecurity risk mitigation activities, informed by the sectors' updated plans and in collaboration with sector stakeholders, the Secretaries of Agriculture and Health and Human Services (as co-SSAs) should direct responsible officials to develop performance metrics to provide data and determine how to overcome challenges to monitoring the food and agriculture sector's cybersecurity progress.

    Agency: Department of Agriculture
    Status: Open

    Comments: The Departments of Agriculture and Health and Human Services released an update to the food and agriculture sector-specific plan for 2015. The plan states the sector's lack of an overarching mechanism to measure and evaluate risk mitigation activities and the challenge of obtaining performance measurement data from non-federal partners. However, the plan notes a goal of evaluating the progress of individual protective programs and strategies. No metrics or reports of outcomes have been provided to address the challenge of monitoring the sector's cybersecurity progress. We will continue to follow up to determine whether USDA and HHS have developed and implemented mechanisms to measure the outcomes of their sector cybersecurity-related activities.
    Recommendation: To better monitor and provide a basis for improving the effectiveness of cybersecurity risk mitigation activities, informed by the sectors' updated plans and in collaboration with sector stakeholders, the Secretaries of Agriculture and Health and Human Services (as co-SSAs) should direct responsible officials to develop performance metrics to provide data and determine how to overcome challenges to monitoring the food and agriculture sector's cybersecurity progress.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The Departments of Agriculture and Health and Human Services released an update to the food and agriculture sector-specific plan for 2015. The plan states the sector's lack of an overarching mechanism to measure and evaluate risk mitigation activities and the challenge of obtaining performance measurement data from non-federal partners. However, the plan notes a goal of evaluating the progress of individual protective programs and strategies. No metrics or reports of outcomes have been provided to address the challenge of monitoring the sector's cybersecurity progress. We will continue to follow up to determine whether HHS has developed and implemented mechanisms to measure the outcomes of its sector cybersecurity-related activities.
    Recommendation: To better monitor and provide a basis for improving the effectiveness of cybersecurity risk mitigation activities, informed by the sectors' updated plans and in collaboration with sector stakeholders, the Secretaries of Homeland Security and Transportation (as co-SSAs) should direct responsible officials to develop performance metrics to provide data and determine how to overcome challenges to monitoring the transportation systems sector's cybersecurity progress.

    Agency: Department of Homeland Security
    Status: Open

    Comments: The co-Sector-Specific Agencies (SSAs) for the Transportation Systems Sector, DHS (TSA and Coast Guard) and the Department of Transportation, provided an update on efforts to develop sector cybersecurity metrics. The update described measures under consideration such as tracking the number of sector stakeholders receiving cybersecurity products, monitoring the usefulness of products through satisfaction surveys, and tracking attendance at sector events and seminars encompassing cybersecurity. The co-SSAs plan to report sector cyber activities, progress, and relevant metrics annually through the Critical Infrastructure National Annual Report and through quadrennial updates to the sector-specific plan. The latest sector-specific plan was released in 2015. The proposed metrics have not been formalized in a strategy or plan. We will continue to monitor and evaluate efforts to formalize and implement the proposed metrics to determine whether they address the intent of the recommendation.
    Recommendation: To better monitor and provide a basis for improving the effectiveness of cybersecurity risk mitigation activities, informed by the sectors' updated plans and in collaboration with sector stakeholders, the Secretaries of Homeland Security and Transportation (as co-SSAs) should direct responsible officials to develop performance metrics to provide data and determine how to overcome challenges to monitoring the transportation systems sector's cybersecurity progress.

    Agency: Department of Transportation
    Status: Open

    Comments: The co-Sector-Specific Agencies (SSAs) for the Transportation Systems Sector, DHS (TSA and Coast Guard) and the Department of Transportation, provided an update on efforts to develop sector cybersecurity metrics. The update described measures under consideration such as tracking the number of sector stakeholders receiving cybersecurity products, monitoring the usefulness of products through satisfaction surveys, and tracking attendance at sector events and seminars encompassing cybersecurity. The co-SSAs plan to report sector cyber activities, progress, and relevant metrics annually through the Critical Infrastructure National Annual Report and through quadrennial updates to the sector-specific plan. The latest sector-specific plan was released in 2015. The proposed metrics have not been formalized in a strategy or plan. We will continue to monitor and evaluate efforts to formalize and implement the proposed metrics to determine whether they address the intent of the recommendation.
    Recommendation: To better monitor and provide a basis for improving the effectiveness of cybersecurity risk mitigation activities, informed by the sectors' updated plans and in collaboration with sector stakeholders, the Administrator of the Environmental Protection Agency should direct responsible officials to develop performance metrics to provide data and determine how to overcome challenges to monitoring the water and wastewater systems sector's cybersecurity progress.

    Agency: Environmental Protection Agency
    Status: Open

    Comments: The 2015 water and wastewater sector-specific plan includes a segment on measuring the effectiveness of sector activities that describes the overall principles for collecting data and using the National Annual Report data calls as a tool for assessing performance and reporting on progress within the sector. However, the plan does not state specific measures and the agency acknowledged in its response to our report that it does not collect performance metrics on the effectiveness of its cybersecurity programs for the sector. According to agency officials, the development of performance metrics in collaboration with sector partners is underway. We will continue to follow up to identify any specific metrics developed and implemented and resulting outcome-based reports.
    Director: J. Lawrence Malenich
    Phone: (202) 512-9399

    1 open recommendations
    Recommendation: The Foundation's Executive Director should update the Foundation's draft written policies and procedures over its contracting practices to include all key internal control activities, issue them in final form, and establish a date by which these actions will be completed.

    Agency: Morris K. Udall and Stewart L. Udall Foundation
    Status: Open

    Comments: The Foundation concurred with our recommendation and stated that it will implement the recommended actions. In addition, the Foundation stated that our recommendations will be incorporated in the Foundation's risk assessment documentation, established as a priority, and included in the Foundation's fiscal year 2016 Corrective Action Plan. As of July 2017, the Foundation has not implemented corrective actions to address this recommendation.
    Director: Linda Kohn
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To improve the measurement of nursing home quality, the Administrator of CMS should establish specific timeframes, including milestones to track progress, for the development and implementation of a standardized survey methodology across all states.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation and in September 2017 reported that CMS is taking steps to address. We will update the status of this recommendation when we receive additional information.
    Recommendation: To improve the measurement of nursing home quality, the Administrator of CMS should establish and implement a clear plan for ongoing auditing to ensure reliability of data self-reported by nursing homes, including payroll-based staffing data and data used to calculate clinical quality measures.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation and in September 2017 reported that CMS is taking steps to address. We will update the status of this recommendation when we receive additional information.
    Recommendation: To help ensure modifications of CMS's oversight activities do not adversely affect the agency's ability to assess nursing home quality and that effective modifications are adopted more widely, the Administrator of CMS should establish a process for monitoring modifications of essential oversight activities made at the CMS central office, CMS regional office, and state survey agency levels to better understand the effects on nursing home quality oversight.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation and in September 2017 reported that CMS is taking steps to address. We will update the status of this recommendation when we receive additional information.
    Director: Linda Kohn
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To ensure effective implementation of the Inclusion Policy in a manner consistent with the Revitalization Act's provisions regarding the design of certain clinical trials, the NIH Director should examine approaches for aggregating more detailed enrollment data at the disease and condition level, and report on the status of this examination to key stakeholders and through its regular biennial report to Congress on the inclusion of women in research.

    Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health
    Status: Open

    Comments: NIH agreed with our recommendation and began discussions in November 2015 regarding conducting these types of analyses. In April and May 2016, NIH officials identified a preliminary strategy for summarizing inclusion data at the disease and condition level. As of August 2017, NIH officials said that due to potential data limitations, NIH will continue to refine methods of reporting at this level, and the agency plans to report enrollment data at the disease and condition level in its next triennial NIH report to Congress, covering fiscal years 2015-2017, to be drafted in fiscal year 2018.
    Recommendation: To ensure effective implementation of the Inclusion Policy in a manner consistent with the Revitalization Act's provisions regarding the design of certain clinical trials, the NIH Director should, on a regular basis, systematically collect and analyze summary data regarding awardees' plans to conduct analyses of potential sex differences, such as the proportion of trials being conducted that intend to analyze differences in outcomes for men and women.

    Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health
    Status: Open

    Comments: In August 2017, NIH reiterated that the agency has established a number of policies and processes to ensure that sex differences are considered in the design of research, but has not taken action specific to this recommendation. We continue to believe that thoughtful, useful analysis and summary reporting would improve NIH's oversight of this aspect of the Inclusion Policy.
    Recommendation: To ensure effective implementation of the Inclusion Policy in a manner consistent with the Revitalization Act's provisions regarding the design of certain clinical trials, the NIH Director should report on this summary data and the results of this analysis in NIH's regular biennial report to Congress on the inclusion of women in research.

    Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health
    Status: Open

    Comments: NIH agreed with our recommendation in commenting on our report. In August 2017, NIH reiterated that the agency has established a number of policies and processes to ensure that sex differences are considered in the design of research, but has not taken action specific to this recommendation. We continue to believe that thoughtful, useful analysis and summary reporting would improve NIH's oversight of this aspect of the Inclusion Policy.
    Director: J. Alfredo Gómez
    Phone: (202) 512-3841

    1 open recommendations
    Recommendation: To enhance HHS's ability to protect public health from the impacts of climate change, the Secretary of HHS should direct CDC to develop a plan describing when it will be able to issue climate change communication guidance to state and local health departments, to better position relevant officials to effectively communicate about the risks that climate change poses to public health and address requirements of the Climate Ready States and Cities Initiative.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of December 2016, CDC has taken steps to start developing a communications strategy, and expects this process to include the development of guidance for public health officials to help them more effectively communicate about the health effects of climate change. CDC expects the strategy to be completed by the fall of 2017.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To be able to identify and address problems that may occur and thus help ensure a smooth transition, the Secretary of Defense should require the Defense Health Agency ensure that planning documents for the expansion include specific requirements to continuously monitor affected beneficiaries, including whether (1) covered medications are available and filled in a timely and accurate manner through mail order and across MTF pharmacies; and (2) beneficiaries are satisfied with the transition to mail order and MTF pharmacies.

    Agency: Department of Defense
    Status: Open

    Comments: As of April 2016, DOD has not provided information that it plans to separately track through mail order and military treatment facilities the availability, timeliness, and accuracy of prescriptions filled by beneficiaries affected by the expansion of the TRICARE pharmacy pilot. Similarly, DOD has not provided information that it plans to separately track through mail order and military treatment facilities the satisfaction of beneficiaries affected by the expansion of the TRICARE pharmacy pilot.
    Director: Brenda S. Farrell
    Phone: (202) 512-3604

    3 open recommendations
    including 3 priority recommendations
    Recommendation: To provide decision makers with appropriate and more complete information on the continuing implementation, management, and oversight of the DHA, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to develop a comprehensive requirements assessment process that accounts for needed future skills through the consideration of potential organizational changes and helps ensure appropriate consideration of workforce composition through the determination of the final status of military personnel within the DHA.

    Agency: Department of Defense
    Status: Open
    Priority recommendation

    Comments: As of April 2017, DOD has taken some steps to implement this action. According to an April 2017 letter from the Acting Principal Deputy Assistant Secretary of Defense (Health Affairs), DOD has established processes and procedures to create an overall personnel management process which are documented in a draft Administrative Instruction estimated to be finalized and published by July 31, 2017.
    Recommendation: To provide decision makers with appropriate and more complete information on the continuing implementation, management, and oversight of the DHA, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to develop a plan for reassessing and revalidating personnel requirements as the missions and needs of the DHA evolve over time.

    Agency: Department of Defense
    Status: Open
    Priority recommendation

    Comments: As of April 2017, DOD has taken some steps to implement this action. According to an April 2017 letter from the Acting Principal Deputy Assistant Secretary of Defense (Health Affairs), DOD has established processes and procedures to create an overall personnel management process which are documented in a draft Administrative Instruction estimated to be finalized and published by July 31, 2017.
    Recommendation: To provide decision makers with appropriate and more complete information on the continuing implementation, management, and oversight of the DHA, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to determine the future of the Public Health and Medical Education and Training shared services by either identifying common functions to consolidate to achieve cost savings or by developing a justification for the transfer of these functions from the military services to the DHA that is not premised on cost savings.

    Agency: Department of Defense
    Status: Open
    Priority recommendation

    Comments: As of April 2017, DOD has taken some steps to implement this action. According to an April 2017 letter from the Acting Principal Deputy Assistant Secretary of Defense (Health Affairs), DOD has changed the designation of its Public Health function from a shared service to a division. This change recognizes the distinction that we previously highlighted between a shared service, or the consolidation of functions previously performed by the military services, and a transfer of functions from the military services to the DHA. The letter states that DOD is in the process of assessing business case analyses for various efficiency efforts, with one proposal estimated to save $613 million over three years. DOD has not taken similar action with regard to its Medical Education and Training shared service. As we previously reported in our prior update, while DOD cites future cost savings in its modeling and simulation and online learning product lines, we reported in 2014 that these initiatives overlap with the DHA's Contracting and Procurement and Information Technology shared services. For example, while cost savings for Modeling and Simulation are allocated to the Medical Education and Training Directorate, implementation costs are to be incurred by the Contracting and Procurement shared service. This recommendation will remain open until DOD either identifies common functions to consolidate within Medical Education and Training to achieve cost savings or develops a justification for the transfer of these functions from the military services to the DHA that is not premised on cost savings.
    Director: James Cosgrove
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should augment MA network adequacy criteria to address provider availability.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation, and noted in a January 2016 update that CMS will review how to augment the MA network adequacy criteria to address provider availability in future years. As of September 2016, agency officials have not implemented this recommendation.
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should verify provider information submitted by MAOs to ensure validity of the Health Services Delivery data.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation, and noted in a January 2016 update that the agency is working to standardize existing protocols to ensure the validity of the Health Services Delivery data submitted by MAOs with regards to exceptions requests and partial county justifications. However, unless CMS verifies provider information submitted by MAOs, the agency cannot be confident that MAOs are meeting network adequacy criteria. As of September 2016, agency officials have not implemented this recommendation.
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should expand network adequacy reviews by requiring that all MAOs periodically submit their networks for assessment against current Medicare requirements.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation. In a January 2016 update, the agency noted that CMS has expanded its reviews to include both existing and new service areas for network adequacy when MAOs apply for a service area expansion, However, unless CMS periodically requires evidence of compliance of all existing MAO networks, the agency cannot be confident that MAOs are meeting network adequacy criteria. As of September 2016, agency officials have not implemented this recommendation.
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should set minimum requirements for MAO letters notifying enrollees of provider terminations and require MAOs to submit sample letters to CMS for review.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation. In a January 2016 update, the agency noted that the Medicare Marketing Guidelines contain best practice suggestions of what should be included in the written termination notice; however, we note in our report those practices are not required, nor are the letters regularly reviewed. The agency also noted that it was considering rulemaking to require that MAOs submit sample written notices of termination to HHS for review and approval. As of September 2016, agency officials have not implemented this recommendation.
    Director: James R. McTigue, Jr.,
    Phone: (202) 512-9110

    3 open recommendations
    Recommendation: To strengthen oversight of the individual shared responsibility and premium tax credit provisions, the Commissioner of Internal Revenue should assess whether or not the data received from the health insurance marketplaces are sufficiently complete and accurate to enable effective correction of tax returns at-filing based on matching with the marketplace data and, if the assessment determines that such corrections would be effective, seek legislative authority to correct tax returns at-filing based on the marketplace data.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: The Internal Revenue Service (IRS) agreed with GAO's recommendation. IRS reports that the quality of data submitted by health insurance marketplaces has improved since the 2015 return filing season, and it continues to use its correspondence process for resolving discrepancies between marketplace data and that reported by the taxpayer after the return has been filed. IRS has not considered requesting legislative authority to correct tax returns at the time of filing based specifically on discrepancies between the data submitted by the health insurance marketplace and reported by the taxpayer. Agency officials believe that would be premature at this time. They noted that a broader legislative initiative has already been proposed that would grant IRS with correctable error authority in cases where the information provided by the taxpayer does not match the information contained in government databases. Should this broad authority be granted in the future, IRS will then consider how to approach correction of tax returns at the time of filing based on discrepancies with health insurance marketplace data. Such authority was also included in the Administration's 2018 budget.
    Recommendation: To strengthen oversight of the individual shared responsibility and premium tax credit provisions, the Commissioner of Internal Revenue should work with CMS to get the total amount of advance PTC paid for the 2014 tax year and establish, as a baseline, the aggregate amount of the gap between advance PTC paid and advance PTC reported for the 2014 tax year, and track this aggregate gap for future tax years to help in evaluating the effectiveness of IRS's PTC education and compliance efforts.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: The Internal Revenue Service (IRS) agreed with GAO's recommendation in part. As one of the ongoing efforts by the IRS to evaluate the effectiveness of its implementation of the premium tax credit (PTC) provision for tax year 2014, IRS plans to perform as analysis of reporting of advance payments of the PTC by the Marketplaces. The results of this analysis and other efforts will help inform the IRS of potential areas for improvement in education, tax filing and compliance activities. IRS has been tracking the amount of advance PTC paid based on summary data provided by the Centers for Medicare & Medicaid Services (CMS) for 2014 and 2015 as well as the gap between the amounts paid compared to the amount reported by taxpayers. However, IRS has not yet resolved all issues with CMS related to properly allocating all payments to 2014 and 2015. Complete data for 2016 are not yet available.
    Recommendation: To strengthen oversight of the individual shared responsibility and premium tax credit provisions, the Commissioner of Internal Revenue should evaluate IRS efforts to collaborate and communicate with key external stakeholders to inform efforts related to implementation of the new 2015 PPACA requirements.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: The Internal Revenue Service (IRS) agreed with GAO's recommendation but has not yet initiated an evaluation of collaboration and communication efforts with external stakeholders. IRS currently utilizes informal feedback processes to share information and identify opportunities for improvement with external stakeholders in implementing the shared responsibility payment and premium tax credit provisions. We continue to encourage IRS to evaluate its collaboration and communication efforts.
    Director: J. Alfredo Gómez
    Phone: (202) 512-3841

    1 open recommendations
    Recommendation: To better ensure that complete information is available to Congress and the public about federal funding and spending for Great Lakes restoration over time, the Director of OMB should ensure that OMB includes all federal expenditures for Great Lakes restoration activities for each of the 5 prior fiscal years and obligations during the current and previous fiscal years in its budget crosscut reports, as required by Pub. L. No. 113-76 (2014).

    Agency: Executive Office of the President: Office of Management and Budget
    Status: Open

    Comments: OMB's fiscal year 2017 Great Lakes Restoration Crosscut Report to Congress, dated January 2017, does not include the required information on federal agencies' expenditures and obligations. We will continue to review future years' reports to determine if they include this information.
    Director: William T. Woods
    Phone: (202) 512-4841

    3 open recommendations
    Recommendation: To ensure consistent implementation of the Buy Indian Act procurement authority across the agencies and to enhance oversight of implementation of the Act at regional offices, the Secretaries of the Interior and Health and Human Services should direct the Bureau of Indian Affairs and Indian Health Service respectively, to clarify and codify their policies related to the priority for use of the Buy Indian Act, including whether the Buy Indian Act should be used before other set-aside programs.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The Department of Health and Human Services (HHS) has made progress towards addressing this recommendation. The Indian Health Service (IHS) is currently working on efforts to revise the Acquisition Management section of the Indian Health Manual to clarify and codify policies related to the priority for use of the Buy Indian Act. IHS plans for the revision to include implementation and reporting mechanisms for contracts awarded under the Buy Indian Act. HHS reported that IHS plans to issue new policy guidance relating to the Buy Indian Act and how it is to be implemented and prioritized in conjunction with other set asides.
    Recommendation: To ensure consistent implementation of the Buy Indian Act procurement authority across the agencies and to enhance oversight of implementation of the Act at regional offices, the Secretaries of the Interior and Health and Human Services should direct the Bureau of Indian Affairs and Indian Health Service respectively, to collect data on regional offices' implementation of key requirements, such as challenges to self-certification.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: Officials at the Department of Health and Human Services' Indian Health Service (IHS) told us they plan to continue oversight to ensure that contractors comply with key requirements such as (1) maintaining the proportion of Indian ownership, (2) not subcontracting more than half the work to other than Indian firms, and (3) providing a preference to Indians in employment, training, and subcontracting. However, as of July 2017, IHS had not provided evidence that they were collecting data on regional offices' implementation of these key requirements. IHS officials told us they plan to incorporate Buy Indian Act policy language and clauses into all contracts and track Buy Indian award actions and obligations. IHS officials also stated they will ensure that the contracting officer authenticates an Indian Economic Enterprise's categorization/credentials, before award and throughout the contract period.
    Recommendation: To ensure consistent implementation of the Buy Indian Act procurement authority across the agencies and to enhance oversight of implementation of the Act at regional offices, the Secretaries of the Interior and Health and Human Services should direct the Bureau of Indian Affairs and Indian Health Service respectively, to include Buy Indian Act contracts as a part of their regular procurement review process.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: Department of Health and Human Services officials told us initial on-site communications to raise awareness of the Buy Indian Act was included in the fiscal year 2017 Indian Health Service (IHS) Procurement Management Reviews (PMR) being conducted at all area offices. Starting in the fall of 2017, IHS plans to develop webinar training sessions to ensure that a large, diverse audience of contracting and management officials have access to the training. IHS will also incorporate the Buy Indian Act Policy into the established annual procurement management reviews beginning in fiscal year 2018 to ensure compliance.
    Director: J. Christopher Mihm
    Phone: (202) 512-6806

    5 open recommendations
    Recommendation: To help ensure that agency review processes provide frequent, regular opportunities to assess progress on agency priority goals (APG), and are conducted in a manner consistent with GPRA Modernization Act of 2010 (GPRAMA) requirements, OMB guidance, and leading practices, the Secretary of Defense should work with the COO and PIO to modify the Department's review processes to ensure that review meetings are led by the agency head or COO.

    Agency: Department of Defense
    Status: Open

    Comments: In July 2017, Department of Defense (DOD) staff informed us that the department's quarterly performance reviews, which had been reinstituted in late 2016, have been put on hold while the department's new strategic plan is under development. According to DOD staff, the quarterly reviews will not resume until after the department's new strategic plan is approved and released. We will continue to monitor the status of actions to address this recommendation.
    Recommendation: To help ensure that agency review processes provide frequent, regular opportunities to assess progress on agency priority goals (APG), and are conducted in a manner consistent with GPRA Modernization Act of 2010 (GPRAMA) requirements, OMB guidance, and leading practices, the Secretary of Defense should work with the COO and PIO to modify the Department's review processes to ensure that review meetings are used to review progress on all APGs at least once a quarter, discuss at-risk goals and improvement strategies, and assess whether specific program activities, policies, or other activities are contributing to goals as planned.

    Agency: Department of Defense
    Status: Open

    Comments: In July 2017, Department of Defense (DOD) staff informed us that the department's quarterly performance reviews, which had been reinstituted in late 2016, have been put on hold while the department's new strategic plan is under development. According to DOD staff, the quarterly reviews will not resume until after the department's new strategic plan is approved and released. We will continue to monitor the status of actions to address this recommendation.
    Recommendation: To help ensure that agency review processes provide frequent, regular opportunities to assess progress on agency priority goals (APG), and are conducted in a manner consistent with GPRA Modernization Act of 2010 (GPRAMA) requirements, OMB guidance, and leading practices, the Secretary of Defense should work with the COO and PIO to modify the Department's review processes to ensure that review meetings are used by participants to identify, agree upon, document and track follow-up actions.

    Agency: Department of Defense
    Status: Open

    Comments: In July 2017, Department of Defense (DOD) staff informed us that the department's quarterly performance reviews, which had been reinstituted in late 2016, have been put on hold while the department's new strategic plan is under development. According to DOD staff, the quarterly reviews will not resume until after the department's new strategic plan is approved and released. We will continue to monitor the status of actions to address this recommendation.
    Recommendation: To help ensure that agency review processes provide frequent, regular opportunities to assess progress on agency priority goals (APG), and are conducted in a manner consistent with GPRA Modernization Act of 2010 (GPRAMA) requirements, OMB guidance, and leading practices, the Secretary of State should work with the COO and PIO to modify the Department's review processes to ensure that progress on each APG is reviewed in an in-person review meeting at least quarterly.

    Agency: Department of State
    Status: Open

    Comments: According to information provided by State Department staff in June 2017, efforts to address this recommendation are currently on hold until a new Chief Operating Officer (COO) for the department has been appointed. Once a new COO is in place the department plans to move forward with in-person quarterly reviews based on the COO's guidance. We will continue to monitor the status of actions to address this recommendation.
    Recommendation: To help ensure that agency review processes provide frequent, regular opportunities to assess progress on agency priority goals (APG), and are conducted in a manner consistent with GPRA Modernization Act of 2010 (GPRAMA) requirements, OMB guidance, and leading practices, the Secretary of State should work with the COO and PIO to modify the Department's review processes to ensure that the reviews are led by the agency head or COO.

    Agency: Department of State
    Status: Open

    Comments: According to information provided by State Department staff in June 2017, efforts to address this recommendation are currently on hold until a new Chief Operating Officer (COO) for the department has been appointed. Once a new COO is in place the department plans to move forward with in-person quarterly reviews based on the COO's guidance. We will continue to monitor the status of actions to address this recommendation.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To eliminate the fragmentation and duplication in the storage of unclassified OEHS data, the Secretary of Defense should determine which IT system--DOEHRS or MESL--should be used to store specific types of unclassified OEHS data, clarify the department's policy accordingly, and require all other departmental and military-service-specific policies to be likewise amended and implemented to ensure consistency.

    Agency: Department of Defense
    Status: Open

    Comments: In November 2016, officials told us that draft versions of the revised DoDI 6490.03, Deployment Health, and the new Defense Health Agency Procedural Instruction (DHA PI) 6490.03, Deployment Health, are still under review with DOD components. These revised and updated documents will address the recommendation on OEHS data storage. Additionally, DoDI 6055.05, Occupational and Environmental Health (OEH), and Military Service and Combatant Command policy and guidance documents are still being revised to be consistent with DoDI 6490.03 and DHA PI 6490.03 after they are published. These revisions will ensure the consistency among policies. As of November 2016, the entire process is expected to be complete within 10 to 14 months.
    Recommendation: To ensure the reliability of OEHS data, the Secretary of Defense should establish clear policies and procedures for performing quality assurance reviews of the OEHS data collected during deployment, to include verifying the completeness and the reasonableness of these data, and require that all other related military-service-specific policies be amended and implemented to ensure consistency.

    Agency: Department of Defense
    Status: Open

    Comments: In August 2016, officials told us that draft versions of the revised DoDI 6490.03, Deployment Health, and the new Defense Health Agency Procedural Instruction (DHA PI) 6490.03, Deployment Health, are in review among the DOD Components. Further, DoDI 6055.05, Occupational and Environmental Health (OEH) and Military Service and Combatant Command policy and guidance documents will be revised to be consistent with DoDI 6490.03 and DHA PI 6490.03 after they are published. In addition, DOD is exploring improvement to the data quality assurance functionality within the Defense Occupational and Environmental Health Readiness System Industrial Hygiene (DOEHRS-IH). A new DOEHRS-IH version (2.0.18.1) was released on August 19, 2016 that contained several system enhancements and defect corrections to improve overall data quality in the system. DOD anticipates additional releases in FY 2017 that will further improve DOEHRS-IH data quality. The revised policies and the new DOEHRS-IH functionality will appropriately address the recommendation on quality assurance of OEHS data.
    Recommendation: To ensure that potential occupational and environmental health risks are mitigated for servicemembers deployed to Iraq and Afghanistan, the Secretary of Defense should require CENTCOM to revise its policy to ensure that base commanders' decisions on whether to implement risk mitigation recommendations identified in OEHSAs are adequately documented and consistently monitored by the appropriate command.

    Agency: Department of Defense
    Status: Open

    Comments: In August 2016, officials told us that the current DoDI 6055.01, DoD Safety and Occupational Health Program, requires DoD components to establish procedures that document, archive, and reevaluate risk management decisions on a recurring basis. Draft versions of the revised DoDI 6490.03, Deployment Health, and the new Defense Health Agency Procedural Instruction (DHA PI) 6490.03, Deployment Health, include language that is consistent with DoDI 6055.01. Additionally, U.S. Central Command Regulation 40-2 (CCR 40-2), which was updated as of March 8, 2016, references the requirement to establish procedures to assure risk management decisions are documented, archived, and reevaluated on a recurring basis. The DOD is also exploring a risk management decision and monitoring functionality in DOEHRS-IH. It has identified and approved the necessary system change requests required to improve risk management decisions and monitoring functionality. These functionalities are primarily focused around the Occupational & Environmental Health Site Assessment (OEHSA) and associated exposure pathways, sampling plans, and assessments. Subject to the availability of FY 2017 funding, DOD will implement the system change requests, and achieve the required enhancements to DOEHRS-IH. These policies once published and the new DOEHRS-IH functionality will appropriately address the recommendation on documenting and monitoring risk management decisions.
    Director: James C. Cosgrove
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To help improve CMS's process for establishing relative values for Medicare physicians' services, the Administrator of CMS should better document the process for establishing relative values for Medicare physicians' services, including the methods used to review RUC recommendations and the rationale for final relative value decisions.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: To help improve the Centers for Medicare & Medicaid Service's (CMS) process for establishing relative values for Medicare physicians' services, in May 2015 we recommended that the Administrator of CMS better document the process, including the methods used to review recommendations from the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) and the rationale for final relative value decisions. CMS concurred with this recommendation, stating that CMS establishes relative values for new, revised, and potentially misvalued physicians' services based on its review of a variety of sources of information, including the RUC. CMS officials told us the agency continues to improve the transparency of its process by proposing and finalizing changes to the process in the annual rule for the Physician Fee Schedule. Officials also told us that the agency is developing a means of displaying the direct practice expense inputs component of relative values in a consistent manner that will allow for greater transparency and documentation of the process, since currently the RUC recommends direct practice expense inputs to CMS through inconsistent formats that are not conducive to public transparency. Officials estimated that this process will take several years to complete. In order to close this recommendation as implemented, CMS will need to demonstrate that it has improved its internal and external documentation of its process for establishing relative values. As of August 2016, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: To help improve CMS's process for establishing relative values for Medicare physicians' services, the Administrator of CMS should develop a process for informing the public of potentially misvalued services identified by the RUC, as CMS already does for potentially misvalued services identified by CMS or other stakeholders.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: To help improve the Centers for Medicare & Medicaid Service's (CMS) process for establishing relative values for Medicare physicians' services, in May 2015 we recommended that the Administrator of CMS develop a process for informing the public of potentially misvalued services identified by the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), as CMS already does for potentially misvalued services identified by CMS or other stakeholders. CMS did not concur with this recommendation, asserting that the RUC is completely independent of CMS, and as such CMS has no authority to set the RUC's agenda for which services are reviewed. CMS reiterated their non-concurrence in February 2016. CMS officials noted that they recognize that some stakeholders, including those who are not participants in the RUC process, may not be aware of the new, revised, and potentially misvalued services that are under review by CMS prior to the establishment of interim final values in a final rule. For this reason and others, CMS proposed and finalized a change in its process for establishing or revising relative values for new, revised, or potentially misvalued services. Beginning in 2016, CMS will begin including proposed values for some of services in the annual proposed rulemaking for the Physician Fee Schedule, which means that the changes in values for these services will be open for public comment prior to them being finalized. In 2017, changes in values for almost all services will be included in the proposed rule for the Physician Fee Schedule. We continue to believe that CMS needs to inform the public of potentially misvalued services identified by the RUC, as the agency does for potentially misvalued services identified by other stakeholders for review. While the elimination of most interim final values in 2017 will allow stakeholders to comment on values before they become effective, we believe it is still important for CMS to inform stakeholders of those services identified by the RUC as potentially misvalued before CMS received RUC recommendations for these services and subsequently publishes the values in the proposed rule each year. Doing so would give stakeholders more time to provide input on values for services if they so choose before CMS included its proposed values in the annual proposed rulemaking, and we worded our recommendation to allow CMS to determine how to inform stakeholders of these services without delaying the timing of its revision of misvalued services.
    Recommendation: To help improve CMS's process for establishing relative values for Medicare physicians' services, the Administrator of CMS should incorporate data and expertise from physicians and other relevant stakeholders into the process as well as develop a timeline and plan for using the funds appropriated by the Protecting Access to Medicare Act of 2014.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: To help improve the Centers for Medicare & Medicaid Service's (CMS) process for establishing relative values for Medicare physicians' services, in May 2015 we recommended that the Administrator of CMS incorporate data and expertise from physicians and other relevant stakeholders into the process, as well as develop a timeline and plan for using the funds appropriated by the Protecting Access to Medicare Act of 2014 (PAMA). CMS concurred with this recommendation, stating that stakeholders have the opportunity each year to nominate potentially misvalued services for review through a public nomination process. In order to develop a timeline and plan for using the funds appropriated by PAMA, CMS is assessing the research conducted by two external contractors to determine the most effective and fiscally responsible way to use the funds. This work is ongoing, and CMS is using this work to understand the data collection limitations that exist and help inform the development of a timeline for the use of PAMA funds. CMS anticipates releasing a contract solicitation prior to the end of the calendar year. In order to close this recommendation as implemented, CMS will need to demonstrate that it has incorporated data and expertise from relevant stakeholders and has developed a timeline and plan for using the funds appropriated by PAMA. As of August 2016, CMS has not provided any additional information about actions to address this recommendation.
    Director: Kathleen M. King
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: CMS should conduct a formal analysis, using its experience and data it has collected since the implementation of the first MAC contracts, to determine whether alternative contracting approaches could be used--even if only for selected MAC contract responsibilities--to help promote improved contractor performance.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Michelle Sager
    Phone: (202) 512-6806

    3 open recommendations
    Recommendation: To better ensure the adherence to requirements for approval and public access to and feedback on significant guidance in accordance with OMB's Final Bulletin for Agency Good Guidance Practices (M-07-07), the Secretary of HHS should develop written procedures for the approval of significant guidance documents.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In comments printed in the April 2015 final report, HHS concurred with the recommendation and stated that it would explore the best mechanism for distributing written procedures for approval of significant guidance. As of August 2017, GAO is working with HHS officials to obtain additional updates and documentation regarding the department's implementation of this recommendation.
    Recommendation: To improve agencies' guidance development, review, evaluation, and dissemination processes for non-significant guidance, we recommend that the Secretaries of USDA, HHS, DOL, and Education should strengthen their selected components' application of internal controls to guidance processes by adopting, as appropriate, practices developed by other departments and components, such as assessment of risk; written procedures and tools to promote the consistent implementation and communication of management directives; and ongoing monitoring efforts to ensure that guidance is being issued appropriately and has the intended effect. Examples of practices that could be adopted more widely include (1) written procedures for guidance production to, among other things, clearly define management roles; (2) improved communication tools, such as routing slips to document management review; and (3) consistent and ongoing monitoring to determine if guidance is being accessed and having the intended effect.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In comments printed in the April 2015 final report, HHS concurred with the recommendation and stated that it would continue to work with its agencies to share best practices and ensure that agency practices are alighted with departmental standards. As of August 2017, GAO is working with HHS officials to obtain additional updates and documentation regarding the department's implementation of this recommendation.
    Recommendation: To improve agencies' guidance development, review, evaluation, and dissemination processes for non-significant guidance, we recommend that the Secretaries of USDA, HHS, DOL, and Education should improve the usability of selected component websites to ensure that the public can easily find, access, and comment on online guidance. These improvements could be informed by the web and customer satisfaction metrics that components have collected on their websites. Some examples of changes that could facilitate public access to online guidance include (1) improving website usability by clarifying which links contain guidance; (2) highlighting new or important guidance; and (3) ensuring that posted guidance is current.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In comments printed in the April 2015 final report, HHS concurred with the recommendation and stated that it would review current links to guidance documents and explore ways to enhance their visibility and usability. As of August 2017, GAO is working with HHS officials to obtain additional updates and documentation regarding the department's implementation of this recommendation.
    Director: Katherine Iritani
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To improve the transparency and accountability of HHS's section 1115 Medicaid demonstration approval process, and to ensure that federal Medicaid funds for the demonstrations do not duplicate other federal funds, the Secretary of Health and Human Services should issue criteria for assessing whether section 1115 expenditure authorities are likely to promote Medicaid objectives.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of August 2016, the Department of Health and Human Services (HHS) has taken some steps to assess whether section 1115 expenditure authorities are likely to promote Medicaid objectives. HHS has posted on its website four "general criteria" for assessing whether a demonstration meets Medicaid program objectives:(1) increase and strengthen overall coverage of low-income individuals in the state; (2) increase access to, stabilize, and strengthen providers and provider networks available to serve Medicaid and low-income populations in the state; improve health outcomes for Medicaid and other low-income populations in the state; or (4) increase the efficiency and quality of care for Medicaid and other low-income populations through initiatives to transform service delivery networks. We believe this is a positive step but maintain that the general criteria are not sufficiently specific to allow a clear understanding of what HHS considers to be approvable for Medicaid purposes. For example, although each of HHS's four general criteria relate to serving low-income or Medicaid populations, HHS does not define low-income or what it means to serve these individuals. Until more specific guidance is established that more precisely explains how demonstrations relate to serving low-income and Medicaid populations, the rationale for the agency?s approvals of expenditure authorities, which can amount to billions of dollars in federal spending, will not be transparent. We will update the status of this recommendation when HHS provides more specific guidance on how it applies these criteria or alternatively issues more specific criteria.
    Recommendation: To improve the transparency and accountability of HHS's section 1115 Medicaid demonstration approval process, and to ensure that federal Medicaid funds for the demonstrations do not duplicate other federal funds, the Secretary of Health and Human Services should ensure the application of these criteria is documented in all HHS's approvals of section 1115 demonstrations, including those approving new or extending or modifying existing expenditure authorities, to inform internal and external stakeholders, including states, the public, and Congress, of the basis for the agency's determinations that approved expenditure authorities are likely to promote Medicaid objectives.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of August 2016, the Department of Health and Human Services (HHS) has taken some steps to ensure the application of the criteria is documented in all approvals of section 1115 demonstrations. HHS stated that since the release of our report, the Centers for Medicare & Medicaid Services (CMS) has been identifying in Medicaid demonstration approval documents which of its general criteria each approved expenditure authority promotes. In a review of section 1115 demonstration approvals issued on or after July 1, 2015 and posted on HHS?s website as of August 12, 2016, we found that approved demonstration expenditure authorities were linked to HHS's general criteria in some but not all approvals. More consistent documentation of the basis for HHS's approvals will provide assurance that HHS is consistently applying its criteria and increase transparency around how individual expenditure authorities are considered to promote Medicaid objectives. We will continue to monitor CMS's efforts in this area.
    Director: Katherine M. Iritani
    Phone: (202) 512-7114

    3 open recommendations
    including 2 priority recommendations
    Recommendation: To improve CMS's oversight of Medicaid payments, the Administrator of CMS should take steps to ensure that states report accurate provider-specific payment data that include accurate unique national provider identifiers (NPI).

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with GAO's recommendation. As of September 2016, CMS has not provided additional information showing that the recommendation has been implemented. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To improve CMS's oversight of Medicaid payments, the Administrator of CMS should develop a policy establishing criteria for when such payments at the provider level are economical and efficient.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS concurred with GAO's recommendation and as of October 2016 was evaluating ways to improve its oversight, including gathering information from states to better inform future policies. In November 2016, CMS plans to publish a proposed rule for public comment to improve the oversight of supplemental payments made to individual providers. Supplemental payments are large lump sum payments that most states make to certain providers and are not based on claims for services provided. According to CMS, the proposed rule will establish criteria for determining the economy and efficiency of Medicaid payments made to individual providers.
    Recommendation: To improve CMS's oversight of Medicaid payments, the Administrator of CMS should, once criteria are developed, develop a process for identifying and reviewing payments to individual providers in order to determine whether they are economical and efficient.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS concurred with GAO's recommendation and as of October 2016 was evaluating ways to improve its oversight, including gathering information from states to better inform future policies. In November 2016, CMS plans to publish a proposed rule for public comment to improve the oversight of supplemental payments made to individual providers. According to CMS, the proposed rule will establish a process for identifying and reviewing payments to individual providers to determine if these payments meet the criteria of economy and efficiency established by the rule.
    Director: Brenda S. Farrell
    Phone: (202) 512-3604

    6 open recommendations
    Recommendation: To improve DOD's ability to prevent sexual assaults of male servicemembers, to increase its responsiveness to male servicemembers who are sexually assaulted, and to help DOD's sexual assault prevention and response program realize the full benefit of the data it collects on sexual assault incidents, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Secretaries of the military services, to develop a plan for data-driven decision making to prioritize program efforts.

    Agency: Department of Defense
    Status: Open

    Comments: DOD was contacted on July 26, 2016 for an update on efforts to address this recommendation and responded that they are working on the report required by the NDAA on male victims of sexual assault and they believe that the report will, at a minimum, take some steps to address this recommendation. DOD also noted that the report required by the NDAA is due in the first quarter of FY 17 and that they will provide us with a copy once it has been approved. We will provide updated information when we confirm any actions the agency has taken in response to this recommendation.
    Recommendation: To improve DOD's ability to prevent sexual assaults of male servicemembers, to increase its responsiveness to male servicemembers who are sexually assaulted, and to address challenges faced by male servicemembers as DOD continues to seek to transform its culture to address sexual assault, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Secretaries of the military services, to develop clear goals with associated metrics to drive the changes needed to address sexual assaults of males and articulate these goals, for example in the department's next sexual assault prevention strategy.

    Agency: Department of Defense
    Status: Open

    Comments: DOD was contacted on July 26, 2016 for an update on efforts to address this recommendation and responded that they are working on the report required by the NDAA on male victims of sexual assault and they believe that the report will, at a minimum, take some steps to address this recommendation. DOD also noted that the report required by the NDAA is due in the first quarter of FY 17 and that they will provide us with a copy once it has been approved. We will provide updated information when we confirm any actions the agency has taken in response to this recommendation.
    Recommendation: To improve DOD's ability to prevent sexual assaults of male servicemembers, to increase its responsiveness to male servicemembers who are sexually assaulted, and to address challenges faced by male servicemembers as DOD continues to seek to transform its culture to address sexual assault, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Secretaries of the military services, to include information about the sexual victimization of males in communications to servicemembers that are used to raise awareness of sexual assault and the department's efforts to prevent and respond to it.

    Agency: Department of Defense
    Status: Open

    Comments: DOD was contacted on July 26, 2016 for an update on efforts to address this recommendation and responded that they are working on the report required by the NDAA on male victims of sexual assault and they believe that the report will, at a minimum, take some steps to address this recommendation. DOD also noted that the report required by the NDAA is due in the first quarter of FY 17 and that they will provide us with a copy once it has been approved. We will provide updated information when we confirm any actions the agency has taken in response to this recommendation.
    Recommendation: To improve DOD's ability to prevent sexual assaults of male servicemembers, to increase its responsiveness to male servicemembers who are sexually assaulted, and to address challenges faced by male servicemembers as DOD continues to seek to transform its culture to address sexual assault, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Secretaries of the military services, to revise sexual assault prevention and response training to more comprehensively and directly address the incidence of male servicemembers being sexually assaulted and how certain behavior and activities--like hazing--can constitute a sexual assault.

    Agency: Department of Defense
    Status: Open

    Comments: DOD was contacted on July 26, 2016 for an update on efforts to address this recommendation and responded that they are working on the report required by the NDAA on male victims of sexual assault and they believe that the report will, at a minimum, take some steps to address this recommendation. DOD also noted that the report required by the NDAA is due in the first quarter of FY 17 and that they will provide us with a copy once it has been approved. We will provide updated information when we confirm any actions the agency has taken in response to this recommendation.
    Recommendation: To improve DOD's ability to prevent sexual assaults of male servicemembers, to increase its responsiveness to male servicemembers who are sexually assaulted, and to help ensure that all of DOD's medical and mental health providers are generally aware of any gender-specific needs of sexual assault victims, and that victims are provided the care that most effectively meets those needs, the Assistant Secretary of Defense for Health Affairs should, in collaboration with the services' Surgeons General, systematically evaluate the extent to which differences exist in the medical and mental health-care needs of male and female sexual assault victims, and the care regimen, if any, that will best meet those needs.

    Agency: Department of Defense: Office of the Assistant Secretary of Defense (Health Affairs)
    Status: Open

    Comments: DOD was contacted on July 26, 2016 for an update on efforts to address this recommendation and responded that they are working on the report required by the NDAA on male victims of sexual assault and they believe that the report will, at a minimum, take some steps to address this recommendation. DOD also noted that the report required by the NDAA is due in the first quarter of FY 17 and that they will provide us with a copy once it has been approved. We will provide updated information when we confirm any actions the agency has taken in response to this recommendation.
    Recommendation: To improve DOD's ability to prevent sexual assaults of male servicemembers, to increase its responsiveness to male servicemembers who are sexually assaulted, and to help ensure that all of DOD's medical and mental health providers are generally aware of any gender-specific needs of sexual assault victims, and that victims are provided the care that most effectively meets those needs, the Assistant Secretary of Defense for Health Affairs should, in collaboration with the services' Surgeons General, develop and issue guidance for the department's medical and mental health providers--and other personnel, as appropriate--based on the results of this evaluation that delineates these gender-specific distinctions and the care regimen that is recommended to most effectively meet those needs.

    Agency: Department of Defense: Office of the Assistant Secretary of Defense (Health Affairs)
    Status: Open

    Comments: DOD was contacted on July 26, 2016 for an update on efforts to address this recommendation and responded that they are working on the report required by the NDAA on male victims of sexual assault and they believe that the report will, at a minimum, take some steps to address this recommendation. DOD also noted that the report required by the NDAA is due in the first quarter of FY 17 and that they will provide us with a copy once it has been approved. We will provide updated information when we confirm any actions the agency has taken in response to this recommendation.
    Director: Linda T. Kohn
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To help ensure that HHS fully addresses its dissemination requirements under PPACA, the Secretary of Health and Human Services should direct AHRQ to expand dissemination efforts to federal and private health plans and vendors of health information technology focused on clinical decision support.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS officials provided information in 2017 on dissemination efforts conducted as part of the Patient-Centered Outcomes Research Clinical Decision Support Learning Network. However, we have not yet identified the extent to which these efforts are specifically focused on federal and private health plans, or on health IT vendors, as specified in the GAO recommendation.
    Recommendation: To help ensure that HHS fully addresses its dissemination requirements under PPACA, the Secretary of Health and Human Services should direct AHRQ to document and complete plans to develop a publicly available database, including plans to meet the needs of various potential users in the general public.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS officials provided information in 2017 to describe AHRQ's approach to address dissemination requirements through a website that includes instructions and links for searching multiple different publicly available databases that have information on comparative effectiveness research. However, we have not yet identified the extent to which AHRQ has plans to meet the needs of various potential users in the general public, as specified in GAO's recommendation.
    Recommendation: To help ensure that HHS fully addresses its dissemination requirements under PPACA, the Secretary of Health and Human Services should direct AHRQ to develop specific plans on how it will collaborate with the National Institutes of Health on its dissemination activities.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: AHRQ officials provided information in 2017 on how AHRQ and NIH officials have been meeting with each other to collaborate on dissemination activities. However, we have not yet identified specific plans for this collaboration, as specified in GAO's recommendation.
    Director: Kay Brown
    Phone: (202) 512-7215

    2 open recommendations
    Recommendation: To improve the consistency of assistance provided to tribes, the Secretary of Health and Human Services should take steps to provide consistent title IV-E guidance to tribes across its regional offices.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In May 2015, HHS hired a tribal coordinator who will work in the Office of the Associate Commissioner of the Children's Bureau. The tribal coordinator's primary functions will include facilitating communication across the regions and with tribes to share experiences and information, so as to ensure greater consistency and clarity. While this hire represents an initial step towards improving communication with tribal title IV-E agencies, more time is needed for the tribal coordinator to implement policies and procedures that will ensure consistent title IV-E guidance to tribes across HHS regional offices. In May 2017, the agency reported that tribal coordinator position was ultimately elevated to the Office of the ACYF Commissioner and became the Commissioner's representative to the Tribes. We await documentation on any guidance provided to the regional offices that would help with consistency.
    Recommendation: To improve the timeliness of assistance provided to tribes, the Secretary of Health and Human Services should establish procedures to ensure reviews of draft title IV-E plans are conducted by regional office staff in a timely manner.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of May 2017, HHS stated that it does not anticipate taking action in response to this recommendation because of its existing protocols for communicating with and responding to tribal title IV-E grantees. We maintain that establishing procedures, including but not limited to timeframes for responses, would help ensure that tribes receive timely feedback from regional offices regarding their draft title IV-E plans.
    Director: James Cosgrove
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To help the Department of Health and Human Services better control spending and encourage efficient delivery of care, Congress should consider requiring Medicare to pay PCHs as it pays PPS teaching hospitals, or provide the Secretary with the authority to otherwise modify how Medicare pays PCHs. To generate cost savings from any reduction in outpatient payments to PCHs, Congress should also provide that all forgone outpatient payment adjustment amounts be returned to the Supplementary Medical Insurance Trust Fund.

    Agency: Congress
    Status: Open

    Comments: The 21st Century Cures Act enacted in December 2016 slightly reduces the additional payments to PCHs for outpatient services furnished on or after January 1, 2018, and returns savings to the Supplementary Medical Insurance Trust Fund. However, the law does not substantively change how PCHs are paid for outpatient services, which differs from how Medicare pays PPS teaching hospitals. In addition, as of March 1, 2017, no legislative action had been identified that changes how PCHs are paid for inpatient services, as GAO suggested in February 2015. Until Medicare pays these cancer hospitals in a way that encourages greater efficiency, Medicare remains at risk for overspending.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    6 open recommendations
    Recommendation: To improve identification of enlisted servicemembers separated for non-disability mental conditions, and to provide reasonable assurance that enlisted servicemembers, including Air Force National Guard members, are separated for non-disability mental conditions as appropriate and in accordance with DOD requirements, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness and the Secretaries of the Army and the Navy and the Commandant of the Marine Corps to use the separation codes specific to a non-disability mental condition or develop another uniform method to track servicemembers who have been separated for specific non-disability mental conditions so that this information can be easily retrieved.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To improve identification of enlisted servicemembers separated for non-disability mental conditions, and to provide reasonable assurance that enlisted servicemembers, including Air Force National Guard members, are separated for non-disability mental conditions as appropriate and in accordance with DOD requirements, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness and the Secretary of the Air Force to take steps to ensure there is an appropriately staffed process to identify and administratively separate enlisted National Guard members who are unable to function effectively in the National Guard because of a non-disability mental condition.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To improve identification of enlisted servicemembers separated for non-disability mental conditions, and to provide reasonable assurance that enlisted servicemembers, including Air Force National Guard members, are separated for non-disability mental conditions as appropriate and in accordance with DOD requirements, the Secretary of Defense should direct the Secretaries of the Army, the Air Force, and the Navy and the Commandant of the Marine Corps to update their services' administrative separation policies to be consistent with DOD regulations for those servicemembers separated for all non-disability mental conditions.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To improve identification of enlisted servicemembers separated for non-disability mental conditions, and to provide reasonable assurance that enlisted servicemembers, including Air Force National Guard members, are separated for non-disability mental conditions as appropriate and in accordance with DOD requirements, the Secretary of Defense should direct the Secretaries of the Air Force and the Navy and the Commandant of the Marine Corps to implement processes to oversee separations for non-disability mental conditions, such as reinstituting the requirement of annual compliance reporting of a sample of administrative separations, using current DOD policy requirements as review criteria for servicemembers of all military services and their Reserve components.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To improve identification of enlisted servicemembers separated for non-disability mental conditions, and to provide reasonable assurance that enlisted servicemembers, including Air Force National Guard members, are separated for non-disability mental conditions as appropriate and in accordance with DOD requirements, the Secretary of Defense should direct the Secretary of the Army to ensure that Army's planned oversight of separations for non-disability mental conditions is implemented and incorporates reservists and National Guard members separated for such conditions, or that Army implement another process to oversee such administrative separations using current DOD policy requirements as review criteria for all servicemembers, including reservists and National Guard members.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To improve identification of enlisted servicemembers separated for non-disability mental conditions, and to provide reasonable assurance that enlisted servicemembers, including Air Force National Guard members, are separated for non-disability mental conditions as appropriate and in accordance with DOD requirements, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to review any processes used by the military services to oversee such administrative separations to ensure compliance with DOD requirements.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: Vijay A. D'Souza
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: In order to ensure that efforts to address prenatal opioid use and NAS are systematically and effectively planned and coordinated across the federal government, the Director of ONDCP should document the process, including discussions held and information considered, of developing action items on prenatal opioid use and NAS. This may include documenting gaps that were considered in developing action items.

    Agency: Executive Office of the President: Office of National Drug Control Policy
    Status: Open

    Comments: In May 2017 and July 2017, ONDCP officials described the process used to develop the action items related to prenatal opioid use and NAS for the 2015 National Drug Control Strategy report. Specifically, officials described working directly with federal agencies to identify proposals for action items and review proposals during an interagency working group meeting in March 2015. However, ONDCP officials could not provide us any formal documentation, such as meeting minutes, showing the process used or what gaps were considered in developing the action items. ONDCP officials also told us the action items related to prenatal opioid use and NAS for the 2015 Strategy have been generally completed. No action items related to prenatal opioid use and NAS were included in the 2016 Strategy and ONDCP officials said they did not know whether any related action items will be included for the 2017 Strategy. We will update the status of this recommendation after future Strategy reports are published.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: To ensure DHA can accurately and consistently assess mental health provider staffing needs across each of the military services, the Secretary of Defense should direct the Secretaries of the Army, Air Force, and Navy to require the medical commands of each military service to include its estimated mental health provider staffing needs generated through PHRAMS in the requirements fields of DHA's quarterly mental health staffing reports.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: The Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to ensure DHA, through the PHRAMS contractor, continue to refine PHRAMS to incorporate the needs of the military services to reduce the need for additional service-specific methods of determining mental health provider staffing needs.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To ensure the Defense Health Agency (DHA) can accurately and consistently assess mental health provider staffing needs across each of the military services, the Secretary of Defense should direct the Secretaries of the Army, Air Force, and Navy to require the medical commands of each military service to report any additional service-specific methods they use to determine their final estimates of mental health provider staffing needs.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: The Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to require the National Capital Region Medical Directorate to include its estimated mental health provider staffing needs generated through PHRAMS in the requirements fields of DHA's quarterly mental health staffing reports.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: Linda Kohn
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To help determine if programs are effective at supporting those individuals with serious mental illness, the Secretaries of Defense, Health and Human Services, Veterans Affairs, and the Attorney General--which oversee programs targeting individuals with serious mental illness--should document which of their programs targeted for individuals with serious mental illness should be evaluated and how often such evaluations should be completed.

    Agency: Department of Defense
    Status: Open

    Comments: The Department of Defense's position is that it already engages in periodic program evaluation of its psychological health programs as required. It noted that on November 24, 2014, the Under Secretary of Defense for Personnel and Readiness directed the Military Departments and other Department of Defense components to assist in an initiative to evaluate Psychological Health and Traumatic Brain Injury programs across the Department of Defense. As of September 2017, we have not received a further update on the Department of Defense's actions. We will continue to monitor these efforts and seek to determine whether they result in documentation of which programs should be evaluated and how such evaluations should be completed.
    Recommendation: To help determine if programs are effective at supporting those individuals with serious mental illness, the Secretaries of Defense, Health and Human Services, Veterans Affairs, and the Attorney General--which oversee programs targeting individuals with serious mental illness--should document which of their programs targeted for individuals with serious mental illness should be evaluated and how often such evaluations should be completed.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS did not concur with this recommendation. The Helping Families in Mental Health Crisis Reform Act of 2016 enacted in December 2016 included a requirement for HHS to develop a strategy for conducting ongoing evaluations of programs related to mental illness--including serious mental illness--and substance use disorders. As of August 2017, HHS is in the process of preparing a report that identifies key programs and activities across the department, as well as summarizes data on those programs and develops criteria for use in prioritizing programs for evaluation. However, this report is not yet complete. We will continue to monitor HHS's efforts in this regard and look for documentation of HHS plans for future evaluations of programs for individuals with serious mental illness.
    Director: Dave Wise
    Phone: (202) 512-2834

    3 open recommendations
    Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and complete and publish a new or updated strategic plan that, among other things, clearly outlines a strategy for addressing NEMT and how it can be coordinated across federal agencies that fund NEMT service.

    Agency: Department of Transportation
    Status: Open

    Comments: The Federal Transit Administration (FTA) concurred with this recommendation. As of November 2016, FTA stated that Administrator-level members of the Coordinating Council on Access and Mobility (CCAM) met in July 2016 to begin the process of developing a strategic plan. A follow-up meeting of the same group is planned for December 2016. According to FTA, it is anticipated this meeting will result in agreement on a strategic plan framework and that interagency working groups will begin implementation of the framework in early 2017. Based on the minutes of the July 2016 CCAM meeting, emerging themes identified for the strategic plan included improved access to medical care and to better coordinate transportation planning, particularly integrating transportation planning into healthcare planning. This recommendation will be kept open pending finalization of the strategic plan framework and how it relates to NEMT.
    Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and finalize and issue a cost-sharing policy and clearly identify how it can be applied to programs under the purview of member agencies of the Coordinating Council that provide funding for NEMT.

    Agency: Department of Transportation
    Status: Open

    Comments: FTA concurred with this recommendation. As of November 2016, FTA stated that Administrator-level members of the Coordinating Council on Access and Mobility met in July 2016 to begin the process of developing a strategic plan. A follow-up meeting of the same group is planned for December 2016. According to FTA, it is anticipated the December meeting will result in agreement on a strategic plan framework and that interagency working groups will begin implementing the plan in early 2017. FTA expects development of a cost-sharing policy and proposed model will be an objective in the strategic plan. We plan to keep this recommendation open pending completion of the strategic plan framework and further information related to implementing this recommendation.
    Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and using the on-going work of the Health, Wellness, and Transportation working group and other appropriate resources, (1) identify the challenges associated with coordinating Medicaid and VA NEMT programs with other federal programs that fund NEMT, (2) develop recommendations for how these challenges can be addressed while still maintaining program integrity and fraud prevention, and (3) report these recommendations to appropriate committees of Congress. To the extent feasible, the Coordinating Council should implement those recommendations that are within its legal authority.

    Agency: Department of Transportation
    Status: Open

    Comments: FTA said they concurred in part with this recommendation. FTA announced the selection of 19 Rides to Wellness Demonstration and Innovative Coordinated Access and Mobility pilot projects, totally about $7.3 million, in September 2016. According to FTA, seven of the 19 projects have a NEMT focus. In addition, during 2016 FTA conducted outreach sessions in various cities throughout the United States to discuss partnership opportunities between the health and transportation industries. FTA stated that a new series of NEMT-specific listening sessions is now underway and additional sessions are planned for 2017. The purpose of these sessions is to identify challenges related to NEMT coordination that will be addressed by Coordinating Council on Access and Mobility (CCAM) working groups in the future. CCAM is also in the process of developing a strategic plan framework. FTA anticipates agreement on this framework in December 2016. The Fixing America's Surface Transportation (FAST) Act requires CCAM to develop and publish a strategic plan. FTA anticipates issues related to this recommendation will be developed through 2020. We plan to keep this recommendation open to further monitor CCAM and FTA progress and the extent challenges are identified and addressed related to better coordinating Medicaid and VA NEMT with other NEMT programs in the federal government, through the strategic plan framework or other actions resulting from the listening sessions.
    Director: Linda T. Kohn
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to include in the CMS Compare websites, to the extent feasible, estimated out-of-pocket costs for Medicare beneficiaries for common treatments that can be planned in advance.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015 CMS indicated that it is working to implement this recommendation. Specifically, it is actively investigating options for allowing a more targeted and consumer-centric individual user experience on Physician Compare. We will follow up to gather additional information from CMS officials as they continue their work.
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to organize cost and quality information in the CMS Compare websites to facilitate consumer identification of the highest-performing providers, such as by listing providers in order based on their performance.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015, CMS indicated that it is working to implement this recommendation. We will follow up to gather additional information from CMS officials as they continue their work.
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to include in the CMS Compare websites the capability for consumers to customize the information presented, to better focus on information relevant to them.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015, CMS indicated that it is working to implement this recommendation. Specifically, it is evaluating feasibility of including estimated out-of-pocket costs on physician compare. We will follow up to gather additional information from CMS officials as they continue their work.
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to develop specific procedures and performance metrics to ensure that CMS's efforts to promote the development and use of its own and others' transparency tools adequately address the needs of consumers.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015, CMS indicated that it is working to implement this recommendation. CMS also noted that Physician Compare is in the early stages of public reporting, and is evaluating the feasibility of listing providers based on their performance in the new carefinder.gov project. We will follow up to gather additional information from CMS officials as they continue their work.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To help ensure adequate and qualified nurse staffing at VAMCs, the Secretary of Veterans Affairs should direct the Interim Under Secretary for Health to enhance VHA's internal controls by completing evaluations of Phase I and Phase II and make any necessary changes to policies and procedures before national implementation of Phase II in all VAMCs.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA agreed with this recommendation and, according to an update received April 2017, VA is taking actions towards addressing this recommendation and expects to complete those actions Fall 2017. When additional information is received GAO will update the recommendation as appropriate.
    Director: Rebecca Gambler
    Phone: (202) 512-8777

    3 open recommendations
    Recommendation: To enhance ICE's ability to analyze and manage detention facility costs, ensure transparency and accountability in the management of detention facilities, and strengthen the oversight mechanisms that ensure detention facilities provide safe, secure, and humane confinement, the Director of U.S. Immigration and Customs Enforcement should assess the extent to which ICE has appropriate internal controls for tracking and managing detention facility costs and develop additional controls as necessary.

    Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
    Status: Open

    Comments: As of December 2016, no additional information had been provided on the status of ICE efforts to address this recommendation. In February 2015, the Department of Homeland Security (DHS) reported that Immigration and Customs Enforcement (ICE) had created a spend plan tool to help track costs for each detention facility. In addition, DHS reported that ICE headquarters and field offices were coordinating to determine the resources needed to track and manage detention facilities costs. To fully address this recommendation, ICE should assess the extent to which the spend plan tool is an appropriate internal control for tracking and managing detention facilities costs and whether additional controls are necessary.
    Recommendation: To enhance ICE's ability to analyze and manage detention facility costs, ensure transparency and accountability in the management of detention facilities, and strengthen the oversight mechanisms that ensure detention facilities provide safe, secure, and humane confinement, the Director of U.S. Immigration and Customs Enforcement should document the reasons facilities cannot be transitioned to the most recent standards.

    Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
    Status: Open

    Comments: The Department of Homeland Security (DHS) did not concur with this recommendation. As of December 2016, no additional information had been provided on the status of Immigration and Customs Enforcement (ICE) efforts to address this recommendation. To fully address this recommendation, ICE should document the reasons detention facilities cannot be transition to the most recent national detention standards.
    Recommendation: To enhance ICE's ability to analyze and manage detention facility costs, ensure transparency and accountability in the management of detention facilities, and strengthen the oversight mechanisms that ensure detention facilities provide safe, secure, and humane confinement, the Director of U.S. Immigration and Customs Enforcement should take additional steps to help ensure that personnel responsible for reviewing and paying facility detention invoices follow internal control procedures to ensure proper payments.

    Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
    Status: Open

    Comments: As of December 2016, no additional information had been provided on the status of ICE efforts to address this recommendation. In October 2014, the Department of Homeland Security (DHS) reported that Immigration and Customs Enforcement (ICE) had issued a new "Receipt & Acceptance" policy applicable to all program offices and would assess if additional internal controls are required and implement any needed ones, as appropriate. In February 2015, DHS reported that ICE had not finalized an impact assessment of the new policy for fiscal year 2014 to determine if additional controls would be required. To fully address this recommendation, ICE should complete an impact assessment of the new policy to determine if additional controls are needed to ensure proper payment of facility detention invoices.
    Director: Beryl H. Davis
    Phone: (202) 512-2623

    2 open recommendations
    Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare and Medicaid Services to develop and implement policies and procedures for responding to nonroutine CCIIO-related financial management information requests, including procedures for documenting the preparation process and the review and approval of the results.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The Department of Health and Human Services (HHS) disagreed with this recommendation. HHS management indicated that it has up-to-date and clearly documented standard operating procedures (SOP) for its normal day-to-day work processes, and did not believe that non-standard data requests lend themselves to documented, standard SOPs. In May 2016, HHS indicated that its position on this issue has not changed. In June 2017, HHS indicated that its position on this issue has not changed. GAO believes the recommendation is still valid.
    Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare and Medicaid Services to identify and evaluate options to facilitate more timely and independently verifiable reporting of CCIIO-related financial management information, such as enhancing Healthcare Integrated General Ledger Accounting System's standard reporting or custom reporting capabilities.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The Department of Health and Human Services (HHS) disagreed with this recommendation. HHS indicated that it tracks appropriations in accordance with all relevant federal laws and regulations, and that the information was complete and verifiable. Federal accounting concepts and standards concerning managerial cost accounting allow flexibility for agency managers to develop costing methods that are best suited to their operational environment. HHS indicated that would continue to evaluate options of enhancing the standard and/or custom reporting capabilities of its core financial system; the Health Integrated General Ledger System (HIGLAS). In May 2016, HHS indicated that its position on this issue has not changed. In June 2017, HHS indicated that its position on this issue has not changed. GAO believes the recommendation is still valid.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To ensure that the Family Caregiver Program is able to meet caregivers' demand for its services, the Secretary of the Department of Veterans Affairs should expedite the process for identifying and implementing an IT system that fully supports the program and will enable VHA program officials to comprehensively monitor the program's workload, including data on the status of applications, appeals, home visits, and the use of other support services, such as respite care.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and stated that its efforts to develop and implement a new IT system has two key steps. First, VA will enhance and stabilize the existing Caregiver Action Tracker IT system. Second, a replacement IT system with new features and capabilities will be implemented by the end of FY 2017. However, in January 2017, VA reported that the short-term stabilization effort for the current IT system continues to experience multiple challenges resulting in significant schedule delays. Furthermore, the replacement IT system--which is partially dependent on the success of the current stabilization effort--has experienced project barriers of its own, and lacks the funding needed for a contract extension to complete the work. According to VA, the successful implementation of the replacement IT system is at significant risk.
    Recommendation: The Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to use data from the IT system, once implemented, as well as other relevant data to formally reassess how key aspects of the program are structured and to identify and implement modifications as needed to ensure that the program is functioning as envisioned so that caregivers can receive the services they need in a timely manner.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with this recommendation; however, in January 2017, VA reported that barriers continue to place the replacement IT system at significant risk as stated in Recommendation 1. In advance of the electronic solution, VA has developed manual processes to obtain and monitor key data points, allowing it to reassess policies and procedures for the Program of Comprehensive Assistance for Family Caregivers. In its June 2015 update, VA stated that the Caregiver Support Program had started collaborating with VA's Health Services Research and Development to establish a Partnered Evaluation Center (PEC). The PEC is assessing the impact of all caregiver support services in order to evaluate their effectiveness and impact on the health and well-being of veterans and caregivers. In January 2017, VA reported that the PEC's initial work had concluded and key findings had been identified.
    Director: Bertoni, Daniel
    Phone: (202) 512-7215

    1 open recommendations
    including 1 priority recommendation
    Recommendation: The Secretary of Veterans Affairs should take steps to better understand both the difficulties faced by readjusting veterans and the characteristics of those who may be more likely to face such difficulties, and use the results to determine how best to enhance its benefits and services to these veterans.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: VA has begun taking steps to better understand the difficulties faced by readjusting veterans but has not yet completed them. Since November 2014, VA reported that it has been working with DOD to develop the joint process for conducting Care Coordination Process Reviews (formerly known as Qualitative Case Reviews), which will focus on reviewing care coordination processes and effectiveness. VA's Interagency Care Coordination Committee (IC3) Policy and Oversight Work Group is revising the policies and procedures for these reviews and has begun a national roll out of the Lead Coordinator initiative, which, according to VA, will improve the level of complex care coordination within and between DOD and VA. After completing a tabletop exercise of case review presentations on October 3, 2016, VA identified areas which needed fine tuning, so it developed open forums for lead coordinators to discuss process and resources. In an effort to enhance its briefings under the Transition Assistance Program, now known as the Transition Goals, Plans, Success program, VA used participant satisfaction data and is developing a long-term survey instrument that will assist VA in identifying and tracking recommended process improvements. In January 2015, VA produced a report on veteran economic competitiveness that recommended that VA develop targeted strategies for vulnerable populations, such as veterans who separate from the military without a GED or high school diploma and veterans who are separating after their rehabilitation. The report also recommended that VA continue to research the educational and economic status of veterans and coordinate with other federal agencies to identify and address gaps in current programs and policies that may result in barriers to economic success among vulnerable segments of the veteran population. GAO will consider this recommendation closed when VA has completed the joint Care Coordination Process Reviews, developed the long-term survey instrument for the Transition Goals, Plans, and Success program, and used the results from these reviews and survey to determine how best to enhance its benefits and services to veterans.
    Director: Brenda S. Farrell
    Phone: (202) 512-3604

    2 open recommendations
    Recommendation: To help ensure that DOD has the necessary information to determine the extent to which cost savings result from any future consolidation of training within METC or the Education and Training Directorate, the Assistant Secretary of Defense for Health Affairs should direct the Director of the DHA to develop baseline cost information as part of its metrics to assess achievement of cost savings.

    Agency: Department of Defense: Office of the Assistant Secretary of Defense (Health Affairs)
    Status: Open

    Comments: The House Report Accompanying the National Defense Authorization Act for Fiscal Year 2015, citing our work on this subject, required DOD to submit a report by January 31, 2015 detailing, among other things, an explanation of the purpose and goals of the medical education and training shared service with regard to its role in improving the cost efficiency of delivering training, including the challenges it will address, the practices it will put in place to address these challenges, and the resulting cost savings. However, as of September 2015, DOD has not submitted this report. Until DOD develops baseline cost information as part of its metrics to assess achievement of cost savings, this recommendation should remain open.
    Recommendation: To help realize the reform effort's goal of achieving cost savings, the Assistant Secretary of Defense for Health Affairs should direct the Director of the DHA to conduct a fully developed business case analysis for the Education and Training Directorate's reform effort. In this analysis the Director should (1) identify the cost-related problem that it seeks to address by establishing the Education and Training Directorate, (2) explain how the processes it has identified will address the costrelated problem, and (3) conduct and document an analysis of benefits, costs, and risks.

    Agency: Department of Defense: Office of the Assistant Secretary of Defense (Health Affairs)
    Status: Open

    Comments: The House Report Accompanying the National Defense Authorization Act for Fiscal Year 2015, citing our work on this subject, required DOD to submit a report by January 31, 2015 detailing, among other things, an explanation of the purpose and goals of the medical education and training shared service with regard to its role in improving the cost efficiency of delivering training, including the challenges it will address, the practices it will put in place to address these challenges, and the resulting cost savings. However, as of September 2015, DOD has not submitted this report. We reported in September 2015 that DOD has not yet presented a fully developed business case for its Medical Education and Training shared service. Until DOD addresses these concerns, this recommendation should remain open.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To eliminate unnecessary program duplication and to achieve increased efficiencies and potential savings within the integrated MHS, Congress should terminate the Secretary of Defense's authority to contract with the USFHP designated providers in a manner consistent with a reasonable transition of affected USFHP enrollees into TRICARE's regional managed care program or other health care programs, as appropriate.

    Agency: Congress
    Status: Open

    Comments: As of April 2017, no actions have been taken.
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    including 2 priority recommendations
    Recommendation: To ensure that MA encounter data are of sufficient quality for their intended purposes, the Administrator of CMS should establish specific plans and time frames for using the data for all intended purposes in addition to risk adjusting payments to MAOs.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS was in general agreement with this recommendation. In January 2017 we reported that CMS had made progress in defining its objectives for using MA encounter data for risk adjustment and in communicating its plans and time frames to MAOs. However, although CMS had formed general ideas of how it would use MA encounter data for purposes other than risk adjustment, it had not specified plans and time frames for most of the additional purposes for which encounter data may be used. These other purposes include activities to support program integrity. As of July 2017, CMS officials told us that the agency had not taken any further actions in response to this July 2014 recommendation.
    Recommendation: To ensure that MA encounter data are of sufficient quality for their intended purposes, the Administrator of CMS should complete all the steps necessary to validate the data, including performing statistical analyses, reviewing medical records, and providing MAOs with summary reports on CMS's findings, before using the data to risk adjust payments or for other intended purposes.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: While in general agreement with this recommendation, HHS did not commit to completing data validation before using MA encounter data for risk adjustment. In January 2017 we reported that CMS had made limited progress toward validating encounter data by having begun compiling basic statistics on the volume and consistency of data submissions and preparing automated summary reports for MAOs indicating the diagnosis information used for risk adjustment. However the agency had not yet taken other important steps identified in its Medicaid encounter data validation protocol, such as establishing benchmarks for completeness and accuracy. In July 2017, CMS officials told us that the agency had not taken any further actions in response to this July 2014 recommendation.
    Director: Debra Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: The Secretary of Defense should require the Director of the Defense Health Agency to enhance existing guidance for the TROs to include more specificity on assessing nonenrolled beneficiaries' access to care. Specifically, the guidance should contain criteria for analyzing and interpreting the nonenrolled beneficiary and civilian provider surveys' results and the beneficiary population sizing model to facilitate a more rigorous and consistent approach across regions for identifying locations with potential access problems and determining whether actions should be taken.

    Agency: Department of Defense
    Status: Open

    Comments: In April 2016, DHA informed us that it has taken action to ensure a consistent approach across the regions for identifying locations with potential access problems and determining whether actions should be taken. Specifically, the TROs agreed in April 2014 to utilize the congressionally directed Survey of Civilian Provider Acceptance of, and Beneficiary Access to TRICARE Standard and Extra survey results as the source to identify areas of low awareness, acceptance and access scores. Once an area has been confirmed as an area of low awareness, acceptance and access, the SME will work with the respective managed care support contractor to develop an improvement action plan. In addition, to standardize analysis and provide for more specificity, in May 2014 the three TROs agreed upon a standardized Beneficiary Population Sizing Model (BPSM), an analytical tool to monitor access to care and beneficiary satisfaction for Standard beneficiaries outside PSAs. The standardized BPSM was implemented in the last TRO TRICARE Standard annual brief to the DHA Deputy Director in January 2016. DHA has noted that they took these actions as a result of our recommendation. Although they have taken these actions, we are awaiting further information regarding whether they enhanced existing guidance for the TROs to include this additional specificity on assessing nonenrolled beneficiaries' access to care. We will update this recommendation once we obtain additional information from DHA.
    Director: Mihm, J Christopher
    Phone: (202) 512-3236

    2 open recommendations
    Recommendation: To improve agencies' retrospective regulatory review processes and reporting, and strengthen linkages between retrospective reviews and agency performance management, the Director of the Office of Management and Budget should direct the Administrator of the Office of Information and Regulatory Affairs to work with regulatory agencies to implement existing guidance, and update guidance where needed, to improve the reporting of outcomes in their retrospective regulatory review plans by taking actions such as: (1) publishing a link to updated plans, which list recent results and anticipated outcomes, on the White House website; (2) submitting evidence that agencies listed updates of their plans on their "Open Government" web pages; (3) providing more comprehensive information on completed reviews in agencies' most recent plans and progress reports by (a) ensuring the most recent published plan contains a complete accounting of all completed reviews rather than expecting readers to review multiple plans, and (b) including the supporting analysis and data for results by listing a link or citation to the related documentation.

    Agency: Executive Office of the President: Office of Management and Budget
    Status: Open

    Comments: In comments on the draft report, OMB staff generally agreed with the recommendation. In responses to questions for the record following a July 2015 Senate hearing on OMB's Office of Information and Regulatory Affairs (OIRA), the OIRA Administrator noted that OIRA has adopted several of the recommendations in GAO-14-268. Regarding this recommendation, the Administrator stated that OIRA posted agencies' retrospective review plans on a central OMB site. As of August 2017, these plans and progress updates are now publicly available, by agency, on the archived OMB website for President Obama's administration (see https://obamawhitehouse.archives.gov/omb/oira/regulation-reform).
    Recommendation: To improve agencies' retrospective regulatory review processes and reporting, and strengthen linkages between retrospective reviews and agency performance management, the Director of the Office of Management and Budget should direct the Administrator of the Office of Information and Regulatory Affairs to ensure that the Office of Information and Regulatory Affairs, as part of its oversight role, monitor the extent to which agencies have implemented the guidance on retrospective regulatory review requirements outlined in the related executive orders and confirm that agencies have identified how they will assess the performance of regulations in the future.

    Agency: Executive Office of the President: Office of Management and Budget
    Status: Open

    Comments: In comments on the draft report, OMB staff generally agreed with the recommendation. In responses to questions for the record following a July 2015 Senate hearing on the Office of Information and Regulatory Affairs' (OIRA) role in the regulatory process, the OIRA Administrator noted that OIRA has adopted several of the recommendations in GAO-14-268. Specifically regarding this recommendation, the Administrator stated that OIRA regularly asks agencies to consider the incorporation of a retrospective review planning component in forward-looking regulations, but as of August 2017 OMB has not responded to GAO's requests to provide additional details.
    Director: Yocom, Carolyn L
    Phone: (202) 512-4931

    3 open recommendations
    including 2 priority recommendations
    Recommendation: To more effectively use CQMs to assess provider performance, the Secretary of Health and Human Services should direct CMS and ONC to develop a comprehensive strategy for ensuring that CQM data collected and reported using certified EHR technology are reliable, including testing for and mitigation of reliability issues arising from variance in certified EHR systems tested to different CQM specifications.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In July 2015, CMS added that the agency is addressing the issue of reliability through the measure development process. Specifically, CMS stated that the agency has made tools available to measure developers which help to clarify the intent of the measure, catch errors in the development process, and minimize measure complexity. As of October 2016, CMS indicated that its National Testing Collaborative oversees implementation testing of quality measures, including testing for reliability issues. However, the agency did not indicate how these efforts constitute a comprehensive strategy, in conjunction with ONC, for achieving CQM reliability, as we recommended. In April 2017, CMS indicated that its pilot test of the National Testing Collaborative proved unsuccessful, and that CMS is continuing to look at how to best incorporate implementation testing into measure development and implementation. The agency did not indicate it has a comprehensive strategy for these efforts. We will update the status of this recommendation when we receive additional information.
    Recommendation: To ensure that CMS and ONC can effectively monitor the effect of the EHR programs and progress made toward goals, the Secretary of Health and Human Services should direct the agencies to develop performance measures to assess outcomes of the EHR programs--including any effects on health care quality, efficiency, and patient safety and other health care reform efforts that are intended to work toward similar outcomes.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In July 2015, CMS noted that the agency is working to align the programs to better enable monitoring using outcome-oriented performance measures and noted that the agency is collecting data that will help them to develop such measures. CMS did not indicate when HHS plans to develop such measures as GAO recommended. In June 2016, CMS also noted that it analyzed the results of the EHR programs as of October 2015, but did not indicate that it used performance measures that assess outcomes. In September 2017, HHS officials provided us a variety of publically available reports, which they indicated show how program participants are progressing in the EHR programs and the related impacts. However, in reviewing those materials, we did not see evidence that HHS has developed outcome-oriented performance measures that align to the intended outcomes of the EHR programs?that is, goals related to improving health care quality, efficiency, and patient safety. We will update the status of this recommendation when we receive additional information.
    Recommendation: To ensure that CMS and ONC can effectively monitor the effect of the EHR programs and progress made toward goals, the Secretary of Health and Human Services should direct the agencies to use the information these performance measures provide to make program adjustments, as appropriate, to better achieve program goals.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In written responses provided by HHS in February 2014, on a draft of the report, the agency indicated that it agrees that outcome-oriented performance measures will be useful to evaluating the extent that the EHR programs--enacted through legislation--achieve the expected results. However, HHS did not identify any specific actions that it might undertake to address our recommendation. In July 2015, CMS indicated that the agency is still working to develop additional performance measures, which is a necessary first step towards implementing our recommendation to HHS that CMS and ONC use the outcome-oriented performance measures to make program adjustments, as appropriate. In September 2017, HHS officials provided us documents, which they indicated show how information gathered through monitoring activities was used to inform the EHR programs. However, in reviewing those materials, we did not see evidence that HHS used information collected through outcome-oriented performance measures noted above. We will update the status of this recommendation when we receive additional information.
    Director: Marcia Crosse
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To enhance its oversight of drug shortages, particularly as the agency fine-tunes the manner in which it gathers data on shortages and transitions from its database to a more robust system, the Commissioner of FDA should conduct periodic analyses using the existing drug shortages database (and, eventually, the new drug shortages information system) to routinely and systematically assess drug shortage information, and use this information proactively to identify risk factors for potential drug shortages early, thereby potentially helping FDA to recognize trends, clarify causes, and resolve problems before drugs go into short supply.

    Agency: Department of Health and Human Services: Food and Drug Administration
    Status: Open

    Comments: In August 2017, FDA reported that it had not conducted any rigorous analysis of predictors of drug shortages nor have new drug risk factors been identified. Although FDA adopted a new, commercially developed data system, the "Shortage Tracker" to track drug shortages in March 2016, it is used to help the Drug Shortage Staff manage their workload. FDA reported that this system has now been fully operational for over a year. However, no trend analysis relating to drug shortages has been conducted and the agency has no plans to conduct such analyses at this time.
    Director: Dicken, John E
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: The Secretary of HHS should direct the Administrator of CMS to monitor the relationship between PPACA-based FULs and the NADACs on an ongoing basis to help determine whether PPACA-based FULs effectively control federal Medicaid expenditures without reducing beneficiary access to drugs subject to FULs over time.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As part of the final rule implementing the PPACA-based FUL formula, CMS monitors the relationship between the FUL and the NADAC for individual drugs on an ongoing basis and ensures that the FUL does not fall below the NADAC. CMS, however, does not monitor the relationship between the FUL and NADAC in aggregate. This monitoring would provide CMS information on the extent to which the FUL effectively controls federal Medicaid expenditures, particularly in cases where there may be potential for over-reimbursement. CMS officials expect that, by mid-2017, many states will determine reimbursement using an average acquisition cost based on the NADAC. As a result, any potential variation between the FUL and NADAC would be reduced according to CMS officials. We plan to obtain state plan amendments from CMS to confirm whether states are reimbursing at an average acquisition cost or using some other methodology to control Medicaid expenditures.
    Director: Kohn, Linda T
    Phone: (202) 512-7114

    5 open recommendations
    Recommendation: To help ensure that qualified CDRs promote improved quality and efficiency of physician care for Medicare beneficiaries, the Secretary of Health and Human Services should direct Centers for Medicare & Medicaid Services (CMS) to establish key requirements for qualified CDRs that focus on improving quality and efficiency. These requirements could include, for example, having CDRs (1) identify key areas of opportunity to improve quality and efficiency for their target populations and collect additional measures designed to address them, (2) collect a core set of measures established by CMS, and (3) demonstrate that their processes for auditing the accuracy and completeness of the data they collect are systematic and rigorous.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As it has since initiation of the qualified CDR program, CMS continues to allow qualified CDRs to choose what quality measures they will track within very broad parameters. While it has developed a PQRS cross-cutting measure set requirement for physicians using other reporting mechanisms, this requirement does not apply to qualified CDRs. CMS officials report that they have addressed data accuracy and completeness by sharing with qualified CDRs issues and discrepancies that have been found in the data submitted so far.
    Recommendation: To help ensure that qualified CDRs promote improved quality and efficiency of physician care for Medicare beneficiaries, the Secretary of Health and Human Services should direct CMS to establish a requirement for qualified CDRs to demonstrate improvement on key measures of quality and efficiency for their target populations.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: CMS officials report that they are working to implement this recommendation, but they have not yet put forward any specific proposals to address it.
    Recommendation: To help ensure that qualified CDRs promote improved quality and efficiency of physician care for Medicare beneficiaries, the Secretary of Health and Human Services should direct CMS to establish a process for monitoring compliance with requirements for qualified CDRs that draws on relevant expert judgment. This process should assess CDR performance on each requirement in a way that takes into account the varying circumstances of CDRs and their available opportunities to promote quality and efficiency improvement for their target populations.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The limited changes for qualified clinical data registries that CMS outlined in its CY2016 proposed rule in July 2015 do not address this recommendation. CMS officials report that they are working to implement this recommendation, but the approach they describe focuses on assessing changes in the data submitted by qualified CDRs over several years.
    Recommendation: To help ensure that qualified CDRs promote improved quality and efficiency of physician care for Medicare beneficiaries, the Secretary of Health and Human Services should determine and implement actions to reduce barriers to the development of qualified CDRs, such as (1) developing guidance that clarifies Health Insurance Portability and Accountability Act requirements to promote participation in qualified CDRs; (2) working with private sector entities to make relevant multipayer cost data available to qualified CDRs; (3) testing one or more models of shared savings between Medicare and qualified CDRs that achieve reduced Medicare expenditures with improved quality of care, and (4) providing technical assistance to qualified CDRs.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The limited changes for qualified clinical data registries that CMS outlined in its CY2016 proposed rule in July 2015 do not address the specific barriers to the development of qualified CDRs that we identified in our report. However, CMS officials report that they have provided technical assistance to qualified CDRs through monthly support calls and an annual kick-off meeting held in spring 2015.
    Recommendation: To help ensure that qualified CDRs promote improved quality and efficiency of physician care for Medicare beneficiaries, the Secretary of Health and Human Services should determine key data elements needed by qualified CDRs--such as those relevant for a required core set of measures--and direct Office of the National Coordinator for Health Information Technology and CMS to include these data elements, if feasible, in the requirements for certification of EHRs under the EHR incentive programs.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The limited changes for qualified clinical data registries that CMS outlined in its CY2016 proposed rule in July 2015 do not address this recommendation.
    Director: King, Kathleen M
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: In an effort to ensure that IHS has meaningful information on the timeliness with which it issues purchase orders authorizing payment under the CHS program and to improve the timeliness of payments to providers, the Secretary of the Department of Health and Human Services (HHS) should direct the Director of IHS to: (1) modify IHS's claims data system to separately track IHS referrals and self-referrals, revise the Government Performance Results Act measure for the CHS program so that it distinguishes between these two types of referrals, and establish separate timeframe targets for these referral types; and (2) improve the alignment between CHS staffing levels and workloads by revising its current practices, where appropriate, to allow available funds to be used to pay for CHS program staff.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2016, HHS officials reported that they have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: As HHS and IHS monitor the effect that new coverage options available to IHS beneficiaries through PPACA have on CHS program funds, the Secretary of HHS direct should the Director of IHS to proactively develop potential options to streamline program eligibility requirements.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2016, HHS officials reported that they have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: Crosse, Marcia G
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: In order to reduce the administrative costs associated with a fragmented MAI grant structure that diminishes the effective use of HHS's limited HIV/AIDS funding, and to enhance services to minority populations, HHS should consolidate disparate MAI funding streams into core HIV/AIDS funding during its budget request and allocation process.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS stated that it does not support the consolidation of Minority AIDS Initiative (MAI)funds into core funding. As of September, 2016, we are still awaiting an update from HHS on the status of any efforts to implement this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: In order to reduce the administrative costs associated with a fragmented MAI grant structure that diminishes the effective use of HHS's limited HIV/AIDS funding, and to enhance services to minority populations, HHS should seek legislation to amend the Ryan White Comprehensive AIDS Resources Emergency Act of 1990 or other provisions of law, as necessary, to achieve a consolidated approach.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS stated that it does not support the consolidation of Minority AIDS Initiative (MAI) funds into core funding. As of September, 2016, we are still awaiting an update from HHS on the status of any efforts to implement this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Crosse, Marcia G
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To improve the usefulness of IACC data and enhance its efforts to coordinate HHS autism activities and monitor all federally funded autism activities, the Secretary of Health and Human Services should direct the IACC and NIH, in support of the IACC, to provide consistent guidance to federal agencies when collecting data for the portfolio analysis and web tool so that information can be more easily and accurately compared over multiple years.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS continues to disagree with this recommendation. In the spring of 2016 NIH released fiscal years 2011 and 2012 data, and in the spring of 2017, it released fiscal year 2013 data and made these data available through the IACC Web Tool. GAO continues to believe that the issuance of consistent guidance could enhance coordination and monitoring and that implementing this recommendation would be beneficial.
    Recommendation: To improve the usefulness of IACC data and enhance its efforts to coordinate HHS autism activities and monitor all federally funded autism activities, the Secretary of Health and Human Services should direct the IACC and NIH, in support of the IACC, to create a document or database that provides information on non-research autism-related activities funded by the federal government and make this document or database publicly available.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS continues to disagree with this recommendation. However, GAO believes that having a document or database that contains current information on these non-research activities is an important aspect of fulfilling the IACC's responsibility to monitor all federal autism activities, not just research. In May 2016, we issued another report on federal autism activities (GAO-16-446). During our work for this engagement, we found that HHS and the IACC have recently taken actions required by the Autism CARES Act that could help coordinate federal non-research autism activities and implement our November 2013 recommendation. First, as directed by the act, in April 2016, the Secretary of Health and Human Services designated an official to serve as the Autism Coordinator to oversee national autism research, services, and support activities and ensure that autism activities funded by HHS and other federal agencies are not unnecessarily duplicative. Secondly, the Act required the development of a strategic plan for autism research, including for services and supports as practicable, for individuals with autism and the families of such individuals. The plan is to include recommendations to ensure that autism research, and services and support activities to the extent practicable, of HHS and other federal departments and agencies are not unnecessarily duplicative. During IACC meetings in 2016, NIH staff and IACC members discussed updating the strategic plan to include services and supports. This plan is expected to be published in calendar year 2017. We acknowledge the steps taken by HHS and the IACC in response to the Autism CARES Act; however, we believe continued action is needed to develop these initial steps into methods for identifying and monitoring non-research autism-related activities funded by the federal government. We believe that continued fulfillment of provisions in the Autism CARES Act could help the department implement GAO's 2013 recommendation.
    Recommendation: To improve the usefulness of IACC data and enhance its efforts to coordinate HHS autism activities and monitor all federally funded autism activities, the Secretary of Health and Human Services should direct the IACC and NIH, in support of the IACC, to identify projects through its monitoring of federal autism activities--including Office of Autism Research Coordination's annual collection of data for the portfolio analysis and the IACC's annual process to update the strategic plan--that may result in unnecessary duplication and thus may be candidates for consolidation or elimination, and identify potential coordination opportunities among agencies.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS continues to disagree with this recommendation. However, GAO questions the purpose and value of devoting federal resources to collecting these data, if they are not then used to ensure federal funds are used appropriately. In May 2016, we issued another report on federal autism activities (GAO-16-446), which among other topics, examined the steps HHS and other federal agencies have taken to improve coordination and help avoid unnecessary duplication in autism research. We reported that HHS has recently taken actions required by the Autism CARES Act that could help coordinate federal autism research and implement our November 2013 recommendation. First, as directed by the act, in April 2016 the Secretary of Health and Human Services designated an official to serve as the Autism Coordinator to oversee national autism research, services, and support activities and ensure that autism activities funded by HHS and other federal agencies are not unnecessarily duplicative. Second, the Autism Cares Act requires that the IACC's strategic plan include recommendations to ensure that autism research funded by HHS and other federal agencies is not unnecessarily duplicative. During IACC meetings in 2016, NIH staff and IACC members discussed updating the strategic plan, including the aforementioned requirement. This plan is expected to be published in calendar year 2017. We acknowledge the steps taken by HHS and the IACC in response to the Autism CARES Act; however, until the designated Autism Coordinator takes steps to meet the act's requirements and the forthcoming strategic plan is published, there is a risk that opportunities to coordinate and create efficiencies and avoid unnecessary duplication in federal autism research will not be seized. We believe that continued fulfillment of provisions in the Autism CARES Act could help the department implement GAO's 2013 recommendation.
    Director: Draper, Debra A
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To provide decision makers with more complete information on the continued appropriateness of the current pharmacy services contract structure, and to ensure the best value and services to the government and beneficiaries, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to conduct an evaluation of the potential costs and benefits of alternative contract structures for the TRICARE pharmacy services contract.

    Agency: Department of Defense
    Status: Open

    Comments: The current TRICARE pharmacy services contract began in May 2015, with 1 base year and 7 option years. DOD officials stated that they intend to conduct an evaluation of the potential costs and benefits of alternative contract structures as they undergo the next acquisition cycle. GAO will continue to follow up on these recommendations as DOD begins its acquisition planning efforts for the next cycle.
    Recommendation: To provide decision makers with more complete information on the continued appropriateness of the current pharmacy services contract structure, and to ensure the best value and services to the government and beneficiaries, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to incorporate such an evaluation into acquisition planning.

    Agency: Department of Defense
    Status: Open

    Comments: DOD officials stated that they intend to include such an evaluation in their acquisition planning for the next acquisition cycle. GAO will continue to follow up on these recommendations as DOD begins its acquisition planning efforts for the next cycle.
    Director: Kohn, Linda T
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To help address the uncertainty NIH faces, related to the potential impact of increasing indirect costs on its funding of future research, the Director of NIH should assess the impact of growth in indirect costs on its research mission, including, as necessary, planning for how to deal with potential future increases in indirect costs that could limit the amount of funding available for total research, including the direct costs of research projects.

    Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health
    Status: Open

    Comments: As of July 7, 2015, NIH provided some information indicating that it had taken action to address our recommendation by tracking the size of indirect costs as a proportion of NIH's overall budget as part of the agency's annual budget planning process and risk assessment program. However, we determined that the actions did not fully address the recommendation because they focus on the agency's overall budget and do not assess the potential ongoing impact of indirect costs for universities on its mission. As of August 2017, NIH officials have not informed us of any additional actions taken to implement this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Crosse, Marcia G
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To improve CTP's ability to operate efficiently, achieve effective results, and plan appropriately, the Secretary of Health and Human Services should direct the Commissioner of FDA to establish performance measures that include time frames for making final decisions on SE submissions and Exemption from SE submissions.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: FDA has established performance measures that include time frames for reviewing and acting on some of its new tobacco product submissions, including regular Substantial Equivalence (SE) submissions and Exemption from SE submissions, received in fiscal years 2015 through 2018. However, as of September, 2017, FDA has not developed performance measures for provisional SE submissions, the type of SE submissions that represent new tobacco products that may continue to be marketed unless and until FDA's Center for Tobacco Products finds that they are not substantially equivalent. We are keeping this recommendation open until the agency establishes performance measures, including time frames for making final decisions, for provisional SE submissions.
    Recommendation: To improve CTP's ability to operate efficiently, achieve effective results, and plan appropriately, the Secretary of Health and Human Services should direct the Commissioner of FDA to monitor FDA's performance relative to those time frames, such as evaluating whether staff are performing reviews of these submissions efficiently and effectively.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: FDA has established and monitors performance measures that include time frames for reviewing and acting on regular SE submissions, Exemption from SE requests, and Modified Risk Tobacco Product applications for fiscal years 2015 through 2018. However, because the agency has not yet reported establishing and monitoring performance measures for provisional SE submissions, we are leaving this recommendation open as of August 2017.
    Director: King, Kathleen M
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To help ensure successful outreach efforts resulting in significant new enrollment, the Secretary of Health and Human Services should direct the Director of IHS to prepare for the increase in eligibility for expanded Medicaid and new coverage options, and the need for enrollment assistance and billing capacity, by realigning current resources and personnel to increase capacity to assist with these efforts.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of January 2017, IHS has reported that it developed a business plan template to help maximize capacity building and enrollment activities at the local level in coordination with IHS Headquarters and Area Offices. The agency reported that it will monitor the overall implementation process through performance plan evaluations of local leadership by their respective Area Directors. Until we receive documentation of these efforts, this recommendation will remain open.
    Recommendation: To help ensure successful outreach efforts resulting in significant new enrollment, the Secretary of Health and Human Services should direct the Administrator of CMS to develop a plan to educate state Medicaid agencies about when coverage status information may be shared between states and IHS facilities, tribal facilities, and urban Indian health programs (I/T/U) facilities and tribes.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of January 2017, CMS officials reported that the agency has implemented a plan to educate state Medicaid agencies about when coverage status information may be shared between states and I/T/U facilities on a case by case basis because of variation in how this information is shared from state to state. Until we receive documentation of the plan and its implementation, this recommendation will remain open.
    Director: St James, Lorelei
    Phone: (202) 512-2834

    4 open recommendations
    Recommendation: A key matter for Congress to consider is whether or not to move forward with a USPS health plan that would result in an increase in retirees' use of Medicare. If Congress decides to approve this proposal, then Congress should also weigh the impact on other issues, including safeguards for all USPS health plan fund assets by placing appropriate constraints on their asset allocations, such as limiting investments to Treasury securities and inflation-indexed Treasury securities or, if Congress chooses to permit investments in non-Treasury securities, constraints on the discount rate for prefunding purposes so as not to anticipate returns on risk-bearing assets in excess of those on Treasury securities before such returns have actually been achieved.

    Agency: Congress
    Status: Open

    Comments: As of May 2017, Congress had not enacted legislation that would create a U.S. Postal Service health plan that would result in an increase in retirees' use of Medicare. Therefore, Congress had not fully addressed the impact of safeguards for all USPS health plan fund assets by placing appropriate constraints on their asset allocations. In September 2015, S.2051: Improving Postal Operations, Service, and Transparency Act of 2015 was introduced to the to the U.S. Senate Committee on Homeland Security and Governmental Affairs. The bill requires all Medicare-eligible postal annuitants and employees enrolled in a U.S. Postal Service health plan to also enroll in Medicare, including parts A, B and D. This bill, however, has not yet been approved by the Senate Committee on Homeland Security and Governmental Affairs.
    Recommendation: A key matter for Congress to consider is whether or not to move forward with a USPS health plan that would result in an increase in retirees' use of Medicare. If Congress decides to approve this proposal, then Congress should also weigh the impact on other issues, including standards for the disposition of any surplus health plan assets that reduce the risk of a new unfunded liability emerging in the future, standards such as amortizing any surplus to mirror the amortization of any unfunded liability, or using any surplus to offset normal cost payments.

    Agency: Congress
    Status: Open

    Comments: As of May 2017, Congress had not enacted legislation that would create a U.S. Postal Service health plan that would result in an increase in retirees' use of Medicare. Consequently, Congress has not fully addressed the issue of standards for the disposition of any surplus health plan assets that reduce the risk of a new unfunded liability emerging in the future, such as amortizing any surplus to mirror the amortization of any unfunded liability, or using any surplus to offset normal cost payments.
    Recommendation: A key matter for Congress to consider is whether or not to move forward with a USPS health plan that would result in an increase in retirees' use of Medicare. If Congress decides to approve this proposal, then Congress should also weigh the impact on other issues, including designation or creation of an independent entity responsible for the selection of actuarial assumptions used to annually determine the funded status of USPS's health plan for purposes of determining prefunding payments.

    Agency: Congress
    Status: Open

    Comments: As of May 2017, Congress had not enacted legislation that would create a U.S. Postal Service health plan that would result in an increase in retirees' use of Medicare. Consequently, Congress has not fully addressed the designation or creation of an independent entity responsible for the selection of actuarial assumptions used to annually determine the funded status of USPS's health plan for purposes of determining prefunding payments.
    Recommendation: A key matter for Congress to consider is whether or not to move forward with a USPS health plan that would result in an increase in retirees' use of Medicare. If Congress decides to approve this proposal, then Congress should also weigh the impact on other issues, including protections for postal employees and retirees that are comparable to those under FEHBP, including a formula for USPS retirees' contribution to the costs of their health coverage.

    Agency: Congress
    Status: Open

    Comments: As of May 2017, Congress had not enacted legislation that would create a U.S. Postal Service health plan that would result in an increase in retirees' use of Medicare. Consequently, Congress has not fully addressed the issue of protections for postal employees and retirees that are comparable to those under FEHBP, including a formula for USPS retirees' contribution to the costs of their health coverage.
    Director: Iritani, Katherine M
    Phone: (202) 512-7114

    2 open recommendations
    including 1 priority recommendation
    Recommendation: To improve the transparency of the process for reviewing and approving spending limits for comprehensive section 1115 demonstrations, the Secretary of Health and Human Services should update the agency's written budget neutrality policy to reflect actual criteria and processes used to develop and approve demonstration spending limits, and ensure the policy is readily available to state Medicaid directors and others.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: HHS does not agree with this recommendation. However, we continue to believe that HHS should have a formal written budget neutrality policy in place that reflects the Department's actual criteria and processes. HHS's written budget neutrality policy was last issued in 2001 and is not publicly available, and staff have acknowledged that aspects of the policy as written do not reflect their current criteria or processes.
    Recommendation: To improve the transparency of the process for reviewing and approving spending limits for comprehensive section 1115 demonstrations, the Secretary of Health and Human Services should reconsider adjustments and costs used in setting the spending limits for the Arizona and Texas demonstrations, and make appropriate adjustments to spending limits for the remaining years of each demonstration.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of September 2016, HHS officials reported that they have not implemented this recommendation. GAO considers it to be open. We will update this information when we receive additional information
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: In order to improve CMS's ability to identify self-referred anatomic pathology services and help CMS avoid unnecessary increases in these services, the Administrator of CMS should insert a self-referral flag on Medicare Part B claim forms and require providers to indicate whether the anatomic pathology services for which the provider bills Medicare are self-referred or not.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) insert a self-referral flag on Medicare Part B claim forms and require providers to indicate whether the anatomic pathology services for which the provider bills Medicare are self-referred or not. The Department of Health and Human Services (HHS) did not concur with this recommendation, noting that CMS does not believe that this recommendation will address overutilization that occurs as a result of self-referral. We continue to believe that such a flag on Part B claims would likely be the easiest and most cost-effective way for CMS to identify self-referred anatomic pathology services and monitor the behavior of those providers who self-refer these services. As of June 2017, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: In order to improve CMS's ability to identify self-referred anatomic pathology services and help CMS avoid unnecessary increases in these services, the Administrator of CMS should determine and implement an approach to ensure the appropriateness of biopsy procedures performed by self-referring providers.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) implement an approach to ensure the appropriateness of biopsy procedures performed by self-referring providers. The Department of Health and Human Services (HHS) does not concur with this recommendation and does not believe it would address overutilization that occurs as a result of self-referral. HHS noted that it would be difficult to make recommendations regarding whether anatomic pathology services are appropriate without reviewing a large number of claims. We continue to believe that it is important for CMS to monitor the self-referral of anatomic pathology services on an ongoing basis and determine if those services are inappropriate or unnecessary. We also continue to believe this can be achieved without reviewing a large number of claims. CMS could, for example, consider performing targeted audits of providers that perform a higher average number of biopsy procedures compared to providers of the same specialty treating similar numbers of Medicare beneficiaries. As of June 2017, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: In order to improve CMS's ability to identify self-referred anatomic pathology services and help CMS avoid unnecessary increases in these services, the Administrator of CMS should develop and implement a payment approach for anatomic pathology services that would limit the financial incentives associated with referring a higher number of specimens--or anatomic pathology services--per biopsy procedure.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) develop and implement a payment approach for anatomic pathology services under the Physician Fee Schedule that would limit the financial incentives associated with referring a higher number of specimens--anatomic pathology services--per biopsy procedure. Although health care providers have discretion in determining the number of tissue samples from biopsy procedures that become specimens (anatomic pathology services), CMS's current payment system under the Physician Fee Schedule provides a financial incentive for providers to refer more specimens per biopsy procedure. Specifically, CMS pays for each specimen that a provider submits to be analyzed. HHS indicated that it concurred with our recommendation and that it had addressed this recommendation by reducing payment for the most commonly furnished anatomic pathology service (Current Procedural Terminology [CPT] code 88305) by approximately 30 percent in calendar year 2013. However, CMS's payment reduction did not change the financial incentive providers have to refer more specimens per biopsy procedure because they will still be paid separately for each specimen submitted. We continue to believe that CMS should develop a payment approach that addresses this incentive. As of June 2017, CMS had not provided any additional information about actions it has taken to address this recommendation.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To help ensure that ADI suppliers provide consistent, safe, and high-quality imaging to Medicare beneficiaries, the Administrator of CMS should determine the content of and publish minimum national standards for the accreditation of ADI suppliers, which could include specific qualifications for supplier personnel and requiring accrediting organization review of clinical images.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: As of September 2016, HHS officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To help ensure that ADI suppliers provide consistent, safe, and high-quality imaging to Medicare beneficiaries, the Administrator of CMS should develop an oversight framework for evaluating accrediting organization performance, which could include collecting and analyzing information on accreditation results and conducting validation audits.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: As of September 2016, HHS officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To help ensure that ADI suppliers provide consistent, safe, and high-quality imaging to Medicare beneficiaries, the Administrator of CMS should develop more specific requirements for accrediting organization mid-cycle audit procedures and clarify guidance on immediate-jeopardy deficiencies to ensure consistent identification and timely correction of serious care problems for the duration of accreditation.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: As of September 2016, HHS officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: Williamson, Randall B
    Phone: (202) 512-7114

    3 open recommendations
    including 1 priority recommendation
    Recommendation: To effectively manage fee basis care spending, the Secretary of Veterans Affairs should revise the beneficiary travel eligibility regulations to allow for the reimbursement of travel expenses for veterans to another VAMC to receive needed medical care when it is more cost-effective and appropriate for the veteran than seeking similar care from a fee basis provider.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of September 2015, VA has taken some actions to address this recommendation, but additional actions are needed to fully implement it. We will update the status of this recommendation when we receive additional information from VA.
    Recommendation: To effectively manage fee basis care wait times and spending, the Secretary of Veterans Affairs should direct the Under Secretary for Health to analyze the amount of time veterans wait to see fee basis providers and apply the same wait time goals to fee basis care that are used as VAMC-based wait time performance measures.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: In October 2014, VHA established a new wait-time goal, which is that veterans should be seen within 30 days of the date that an appointment is deemed clinically appropriate by a VA health care provider, or if no such clinical determination has been made, the date a veteran prefers to be seen for hospital care or medical services. While VHA has been monitoring the timeliness of VHA-based care according to this standard, it has not been applying the same standard to community-based care, including care delivered through the Veterans Choice Program. Therefore, VHA cannot determine whether veterans are receiving care in the community sooner or later than they otherwise would receive care at VA medical facilities. To fully implement this recommendation, VHA needs to take steps to ensure that its wait-time policies and procedures for both VHA-based care and community-based care (fee basis care) are aligned.
    Recommendation: To ensure that VA Central Office effectively monitors fee basis care, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that fee basis data include a claim number that will allow for VA Central Office to analyze the episode of care costs for fee basis care.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of September 2015, VA has taken some actions to address this recommendation, but additional actions are needed to fully implement it. We will update the status of this recommendation when we receive additional information from VA.
    Director: King, Kathleen M
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To improve the effectiveness of the unpublished MUEs and better ensure Medicare program integrity, the CMS Administrator should consider periodically reviewing claims to identify the providers exceeding the unpublished MUE limits and determine whether their billing was proper.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: In its comments on a draft of this report, HHS concurred with this recommendation and indicated that CMS would conduct further analysis to determine the most appropriate way to respond. In July 2015, HHS told us that CMS has established a process to identify providers exceeding the unpublished MUE limits and determine whether their billing was proper. In August 2016, CMS informed us that the agency is developing a process to review provider level data to determine potential improper billing that exceeds unpublished MUE limits. However, as of September 2016, CMS has not yet implemented this process. We requested that CMS provide documentation of the process once it has been implemented. With this documentary support, we hope to close the recommendation.
    Director: Crosse, Marcia G
    Phone: (202)512-3407

    2 open recommendations
    Recommendation: To help ensure that HHS is adequately and comprehensively assessing HPP and PHEP awardees' performance and progress in meeting the medical and public health preparedness goals of the cooperative agreements, the Secretary of Health and Human Services should direct ASPR and CDC to develop objective and quantifiable performance targets and incremental milestones that correspond to the new HPP and PHEP performance measures, against which HHS can gauge progress toward the medical and public health preparedness goals of the cooperative agreements and direct technical assistance, as needed.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: Since we examined the HPP and PHEP cooperative agreements in 2012, ASPR had developed few targets for the HPP program measures or their corresponding indicators that were contained in the HPP performance measurement guidance documents issued for Budget Periods (BP) 2-5, ending June 30, 2017. Additionally, the new HPP performance measure implementation guidance for the 5-year project cycle from 2017-2022 introduces 28 performance measures, with few having targets?the guidance notes that corresponding goals or targets may be set at a later date after data from the first budget period of this new project cycle has been reviewed. Regarding PHEP, CDC had developed performance targets for about half of the performance measures as of the PHEP BP5 performance measurement guidance (BP5 ended June 30, 2017). These performance measures generally remain the same, with existing targets, for BP1 (July 1, 2017-June 30, 2018) of the new 5-year budget cycle. GAO recognizes that it may not be appropriate to develop performance targets for every performance measure depending on the desired process or outcome; however, both agencies still have work to do in this area.
    Recommendation: To help ensure that HHS is adequately and comprehensively assessing HPP and PHEP awardees' performance and progress in meeting the medical and public health preparedness goals of the cooperative agreements, the Secretary of Health and Human Services should ensure that performance measures and targets remain consistent across the 5-year project cycle and that any future measures be comparable to determine whether awardees are making progress toward meeting short- and long-term medical and public health preparedness goals of the cooperative agreements.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: Since we first examined the HPP and PHEP cooperative agreements in 2012, ASPR and CDC had made efforts to maintain consistency in their performance measures, particularly in the last 3 years of the prior project cycle which ended June 30, 2017. However, because part of the recommendation includes consistency of performance measures into future project cycles, we also examined whether both cooperative agreements continued to use basically the same performance measures into the current 5-year cycle, which began July 1, 2017. ASPR's HPP has made a significant change in its performance measures, introducing a new set of 28 performance measures for this new 5-year cycle. CDC's PHEP performance measures generally remained consistent in the last two budget periods of the prior 5-year cycle, and remained generally the same for the first year of the new 5-year cycle (some measures were "retired," though key components from a measure may continue to be used by CDC in other types of reviews). As a result of the change to HPP's measures, GAO anticipates keeping this recommendation open at least for the next few budget periods, in order to determine whether HPP maintains consistency with its new performance measures during the new project cycle.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To reduce the incentive for facilities to restrict their service provision to avoid reaching the LVPA treatment threshold, the Administrator of CMS should consider revisions such as changing the LVPA to a tiered adjustment.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: CMS stated in April 2017 that the agency would continue examining the performance of the LVPA to determine whether a tiered adjustment is warranted.
    Director: Kohn, Linda T
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To ensure that nonmedical DOD research organizations coordinate with the Assistant Secretary of Defense for Health Affairs early in the research process to understand medical research requirements and avoid inefficiencies that may lead to duplicative work, the Secretary of Defense should direct the Under Secretary of Defense for Acquisition, Technology and Logistics to communicate to DOD's nonmedical research organizations the importance of coordination with the Joint Program Committee for Combat Casualty Care chair on combat casualty care issues, and require this coordination early in the research process when these organizations conduct research with implications for combat casualty care.

    Agency: Department of Defense
    Status: Open

    Comments: DOD took several actions in 2014 to communicate to DOD's nonmedical research organizations the importance of coordination with the Joint Program Committee for Combat Casualty Care. Specifically, DOD chartered the Armed Services Biomedical Research Evaluation and Management Community of Interest to include both medical and non-medical researchers and to improve coordination, collaboration, and cooperation. DOD also appointed senior leaders to work in both this community of interest and in other DOD research communities of interest, to improve coordination. Furthermore, DOD conducted joint research meetings to share research data across the medical and non-medical communities. As of September 2017, DOD had not indicated a requirement for this coordination to occur early in the research process, as included in GAO's recommendation.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: As CMS continues to implement and refine the Value Modifier program to enhance the quality and efficiency of physician care, the Administrator of CMS should consider whether certain private-sector practices could broaden and strengthen the program's incentives. Specifically, she should consider (1) developing at least some performance benchmarks that reward physicians for improvement as well as for meeting absolute performance benchmarks, and (2) making Value Modifier adjustments more timely in order to better reflect recent physician performance.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: CMS stated that it is working to implement GAO's recommendation. Previously, the agency noted that it would investigate accelerating the timeline of the Value Modifier, keeping in mind reporting requirements, data availability, and the need for valid and reliable measures. In addition, Congress passed legislation in 2015 requiring CMS to incorporate certain benchmark methodology and timing aspects that reflect GAO's 2013 recommendation, and the agency is replacing the Value Modifier with a new merit-based incentive payment system. CMS's efforts may, in time, address GAO recommendations to improve performance benchmarks and the timeliness of payment adjustments, but they have yet to be fully implemented. As of August 2017, CMS officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: The Administrator should develop a strategy to reliably measure the performance of solo and small physician practices, such as by aggregating their performance data to create informal practice groups.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: CMS stated that it is working to implement GAO's recommendation to measure the performance of solo and small physician practices. CMS included in its Value Modifier policies the amount of payment adjustments for solo and small physician practices, along with the parameters for measurement. In addition, Congress passed legislation in 2015 requiring CMS to establish a process to allow solo and physician practices under ten eligible professionals to be measured in a virtual group, and the agency is replacing the Value Modifier with a new merit-based incentive payment system. CMS's efforts may, in time, address GAO recommendations to reliably measure the performance of solo and small physician practices, but they have yet to be fully implemented. As of August 2017, CMS officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: Draper, Debra A
    Phone: (202) 512-7114

    4 open recommendations
    including 2 priority recommendations
    Recommendation: To ensure reliable measurement of veterans' wait times for medical appointments, the Secretary of VA should direct the Under Secretary for Health to take actions to improve the reliability of wait time measures either by clarifying the scheduling policy to better define the desired date, or by identifying clearer wait time measures that are not subject to interpretation and prone to scheduler error.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: VA concurred with our recommendations to revise its scheduling policy to implement more reliable wait time measures and require all schedulers to complete standardized training on a revised scheduling policy. In July 2016, VA published VHA Directive 1230-Outpatient Scheduling Processes and Procedures, which updated and replaced the prior policy. Although the updated directive provides new instructions for scheduling appointments, the new instructions, which form the basis for measuring wait times, are still subject to scheduler interpretation, making training vital to consistent and accurate implementation of the policy. According to VHA, Directive 1230 was developed to correspond with a technical enhancement to the scheduling system, known as the Vista Scheduling Enhancement (VSE), which will also require training. As of November 2016, VHA reported that the majority of staff with scheduling access had been trained on the new directive and that separate training on VSE was scheduled to begin in February 2017. GAO cannot assess whether VHA scheduling staff are accurately implementing the new scheduling policy until the VSE roll-out is complete and all relevant staff are trained on the new system.
    Recommendation: To better facilitate timely medical appointment scheduling and improve the efficiency and oversight of the scheduling process,the Secretary of VA should direct the Under Secretary for Health to take actions to ensure that VAMCs consistently and accurately implement VHA's scheduling policy, including use of the electronic wait list, as well as ensuring that all staff with access to the VistA scheduling system complete the required training.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: VA concurred with our recommendations to revise its scheduling policy to implement more reliable wait time measures and require all schedulers to complete standardized training on a revised scheduling policy. In July 2016, VA published VHA Directive 1230-Outpatient Scheduling Processes and Procedures, which updated and replaced the prior policy. Although the updated directive provides new instructions for scheduling appointments, the new instructions, which form the basis for measuring wait times, are still subject to scheduler interpretation, making training vital to consistent and accurate implementation of the policy. According to VHA, Directive 1230 was developed to correspond with a technical enhancement to the scheduling system,known as the Vista Scheduling Enhancement (VSE), which will also require training. As of November 2016, VHA reported that the majority of staff with scheduling access had been trained on the new directive and that separate training on VSE was scheduled to begin in February 2017. GAO cannot assess whether VHA scheduling staff are accurately implementing the new scheduling policy until the VSE roll-out is complete and all relevant staff are trained on the new system.
    Recommendation: To improve timely medical appointment scheduling, the Secretary of VA should direct the Under Secretary for Health to develop a policy that requires VAMCs to routinely assess clinics' scheduling needs and resources to ensure that the allocation of staffing resources is responsive to the demand for scheduling medical appointments.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with this recommendation and noted that it would ask VA facilities to routinely assess clinics' availability and ensure staff are distributed to meet access standards for clinics, as well as revising and implementing improved clinic management tools. In February 2015, VHA noted that it had finalized a Scheduling Resource Assessment report to address this recommendation. In December 2016, VHA noted that the Scheduling Resource Assessment tool had been further enhanced and clarified that the training for this tool is not mandatory and use of the tool is optional. Although VHA has developed this and other tools, such as the Clinic Access Report, Wait Time List Report, Missed Opportunity report, it has not developed and implemented a policy that requires VAMCs to routinely assess clinics' scheduling needs and resources. Without such policy, we believe it is not clear how these tools should be used together or who is responsible for assessing scheduling needs and resources and for making operational decisions. To close this recommendation, VA needs to develop a policy that requires its medical centers to routinely assess clinics' scheduling needs and resources to ensure that the allocation of staffing resources is responsive to the demand for scheduling medical appointments.
    Recommendation: To improve timely medical appointments and to address patient and staff complaints about telephone access,the Secretary of VA should direct the Under Secretary for Health to ensure that all VAMCs provide oversight of telephone access and implement best practices outlined in its telephone systems improvement guide.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with this recommendation and stated that VISN and VA Medical Center leadership would use best practices to develop and implement improved telephone service plans. As of March 2015, VHA had developed a standardized telephone assessment tool and requested that facilities that care for 5,000 or more veterans complete the assessment and select actions for improvement based on its existing telephone systems improvement guide. Based on this request, VHA received telephone assessment and improvement plans from 286 facilities that care for 5,000 or more veterans. VHA is monitoring the facilities' telephone performance and is re-baselining call center infrastructure at each facility with a survey and new performance goals. In September 2015, VHA issued an updated Telephone Access and Contact Management Improvement Guide. VHA has also drafted an update to its directive on telephone access, but as of January 2017, it had not been published.
    Director: Iritani, Katherine M
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To improve transparency of and accountability for Medicaid non-DSH supplemental payments, Congress should consider requiring the Administrator of CMS to (1) improve state reporting of non-DSH supplemental payments, including requiring annual reporting of payments made to individual facilities and other information that the agency determines is necessary to oversee non-DSH supplemental payments; (2) clarify permissible methods for calculating non-DSH supplemental payments; and (3) require states to submit an annual independent certified audit verifying state compliance with permissible methods for calculating non-DSH supplemental payments.

    Agency: Congress
    Status: Open

    Comments: As of August 2017, no legislation had been enacted although at least one bill had been introduced in the Congress that would implement this Matter. If enacted, H.R. 541 would, among other things, require annual reporting of non-DSH supplemental payments made to individual institutional providers; information on type of ownership of providers that received the supplemental payments; and other information the agency determines is necessary to oversee non-DSH supplemental payments. However, CMS has taken some actions administratively to understand how to improve its oversight, which are underway. CMS had planned to publish a proposed rule for public comment in fall 2016 that could improve the oversight of supplemental payments made to individual providers. As of August 2017, the agency stated that it is gathering information from data submitted by states to better inform individual provider level payment criteria and establish policies and procedures to evaluate whether payments at the provider level are economic and efficient. They expect to complete this process by March 2018. CMS has also awarded a contract to review Medicaid supplemental payment information submitted by states that may, according to CMS officials, provide information to identify areas for future supplemental payment oversight, including issuing additional guidance on non-DSH supplemental payment submissions and developing standardized formatting. CMS reported that in 2016 it received approval from the Office of Management and Budget to issue standardized templates for all states to use when submitting the annual non-DSH supplemental payments for agency review, but did not specify when standard templates would be used. CMS also reported that the agency was developing a tool to assist in reviewing amendments to state plans and analyzing non-DSH supplemental payments. GAO plans to continue to monitor congressional action, as well as CMS's guidance on supplemental payments to individual providers and actions resulting from the contracted review to determine the extent to which improve state reporting of non-DSH supplemental payments, clarify permissible methods for calculating non-DSH supplemental payments, and require audits to verify that states use permissible methods to calculate non-DSH supplemental payments.
    Director: Draper, Debra A
    Phone: (202)512-3000

    6 open recommendations
    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should expedite and communicate a plan with time frames for when iEHR solutions will be made available to joint ventures and other collaboration sites.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information
    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should expedite and communicate a plan with time frames for when iEHR solutions will be made available to joint ventures and other collaboration sites.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information
    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should take steps to resolve problems with collaboration sites' incompatible business and administrative processes, including reimbursement for services, collection of workload information, dual credentialing, and computer security training.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information
    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should take steps to resolve problems with collaboration sites' incompatible business and administrative processes, including reimbursement for services, collection of workload information, dual credentialing, and computer security training.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information
    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should clarify, as part of the newly initiated joint efforts to address base access, departmental guidance regarding collaboration to include a discussion of base access issues that local officials should consider when discussing and planning collaboration efforts; this could include a discussion of successful approaches that current collaboration sites have adopted to facilitate base access for veterans and their escorts.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information
    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should clarify, as part of the newly initiated joint efforts to address base access, departmental guidance regarding collaboration to include a discussion of base access issues that local officials should consider when discussing and planning collaboration efforts; this could include a discussion of successful approaches that current collaboration sites have adopted to facilitate base access for veterans and their escorts.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information
    Director: Cosgrove, James C
    Phone: (202)512-7029

    3 open recommendations
    including 3 priority recommendations
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should insert a self-referral flag on its Medicare Part B claims form and require providers to indicate whether the advanced imaging services for which a provider bills Medicare are self-referred or not.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS did not concur with this recommendation, noting that CMS did not think this recommendation would be effective in addressing overutilization resulting from self-referral and that it would be complex to administer. We continue to believe that such a flag on Part B claims would likely be the easiest and most cost-effective way for CMS to identify self-referred advanced imaging services and monitor the behavior of those providers who self-refer these services even though the agency has no plans to take further action. As of October 2016, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should determine and implement a payment reduction for self-referred advanced imaging services to recognize efficiencies when the same provider refers and performs a service.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS did not concur with this recommendation, noting that CMS did not believe that a payment reduction would address overutilization that occurs as a result of self-referral and that the agency's multiple procedure payment reduction policy for advanced imaging already captures efficiencies inhering in providing multiple advanced imaging services by the same physician. Further, CMS officials stated that providers in self-referring arrangements could avoid this reduction by having one provider refer an advanced imaging service while having another perform the service. Finally, CMS questioned whether implementing our recommendation would violate the Medicare statute prohibiting paying a differential by physician specialty for the same service. Our recommendation, however, refers to specific self-referral arrangements in which the same provider refers and performs an imaging service, and therefore would not be addressed by CMS's multiple procedure payment reduction policy. As noted in our report, this payment reduction would affect about 10 percent of advanced imaging services referred by self-referring providers. In addition, while CMS raised questions about whether implementing our recommendation would violate Medicare's prohibition on paying a differential by physician specialty for the same service, the agency did not indicate how it would do so as of October 2016. We continue to believe that CMS should determine and implement a payment reduction to recognize efficiencies for advanced imaging services referred and performed by the same provider even though, as of October 2016, the agency has no plans to take further action.
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring providers.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS noted that it would consider this recommendation. The Secretary of HHS has the authority to establish a program to promote the use of appropriate use criteria - criteria that are evidenced-based (to the extent feasible) and that assist professionals to make the most appropriate treatment decisions for a specified clinical condition - for advanced imaging services under the Protecting Access to Medicare Act of 2014. CMS has begun developing its appropriate use criteria program (e.g., in November 2015, CMS established criteria to identify Qualified Provider Led Entities that are responsible for developing appropriate use criteria and has since selected Qualified Provider Led Entities), but full implementation of the program will not occur until at least January 1, 2018. If it - and the subsequent prior authorization program that incorporates appropriate use criteria - are implemented broadly enough (i.e., they ensure the appropriateness of advanced imaging services by all physicians, including those who self-refer), we could close the recommendation.
    Director: Cosgrove, James C
    Phone: (202)512-7029

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To increase D-SNPs' accountability and ensure that CMS has the information it needs to determine whether D-SNPs are providing the services needed by dual-eligible beneficiaries, especially those who are most vulnerable, the Administrator of CMS should conduct an evaluation of the extent to which D-SNPs have provided sufficient and appropriate care to the population they serve, and report the results in a timely manner.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: As of October 2016, HHS has not implemented this recommendation. CMS noted that, in 2012, they conducted two independent reviews to evaluate how well SNPs, including D-SNPs, developed and implemented a quality improvement tool used to ensure that the unique needs of SNP enrollees are identified and addressed through the plan's care management practices. However, CMS has not conducted an evaluation of the extent to which D-SNPs have provided sufficient and appropriate care to the population they serve. In prior updates, CMS officials said that they were uncertain whether an evaluation of D-SNPs would be conducted in the future, since the likelihood of an evaluation would be dependent on availability of funding for an independent contract. However, they noted that, to the extent that CMS is able to develop solid care coordination outcome measures (which would be incorporated into the HEDIS requirements), that they expect these measures will serve as key indicators of D-SNP performance. For this recommendation to be closed as implemented, CMS will need to conduct an evaluation of the extent to which D-SNPs have provided sufficient and appropriate care to the population they serve.
    Director: Draper, Debra A
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To clarify IT requirements within the Executive Agreement, to enable VA and DOD to make an informed recommendation about whether the FHCC should continue after the end of the demonstration, and to provide useful information for other integrations that may be considered in the future, the Secretaries of Veterans Affairs and Defense should develop plans with clear definitions and specific deliverables, including time frames for two IT capabilities-documentation of patient care to support medical and dental operational readiness and outpatient appointment enhancements-and formalize these plans, for example, by incorporating them into the Executive Agreement.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of July 2017, VA and DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To clarify IT requirements within the Executive Agreement, to enable VA and DOD to make an informed recommendation about whether the FHCC should continue after the end of the demonstration, and to provide useful information for other integrations that may be considered in the future, the Secretaries of Veterans Affairs and Defense should develop plans with clear definitions and specific deliverables, including time frames for two IT capabilities-documentation of patient care to support medical and dental operational readiness and outpatient appointment enhancements-and formalize these plans, for example, by incorporating them into the Executive Agreement.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, VA and DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: King, Kathleen M
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: In order to ensure an equitable allocation of CHS program funds, the Congress should consider requiring IHS to develop and use a new method to allocate all CHS program funds to account for variations across areas that would replace the existing base funding, annual adjustment, and program increase methodologies, notwithstanding any restrictions currently in federal law.

    Agency: Congress
    Status: Open

    Comments: As of January 2017, Congress has not acted on this recommendation. We will update the status of this recommendation if Congress takes action.
    Recommendation: To make IHS's allocation of CHS program funds more equitable, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to require IHS to use actual counts of CHS users, rather than all IHS users, in any formula for allocating CHS funds that relies on the number of active users.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of January 2017, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: To make IHS's allocation of CHS program funds more equitable, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to require IHS to use variations in levels of available hospital services, rather than just the existence of a qualifying hospital, in any formula for allocating CHS funds that contains a hospital access component.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of January 2017, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: To make IHS's allocation of CHS program funds more equitable, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to develop written policies and procedures to require area offices to notify IHS when changes are made to the allocations of funds to CHS programs.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of January 2017, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Draper, Debra A
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To systematically gauge the extent to which deficiencies identified by individual AIBs may be occurring throughout VHA; and to maximize opportunities for sharing information across VHA to improve its overall operations, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish a process to collect and analyze aggregate data from AIB investigations, including the number of investigations conducted, the types of matters investigated, whether the matters were substantiated, and systemic deficiencies identified.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with this recommendation and noted that it would explore any new processes for collecting and analyzing aggregate data from AIB investigations. In September 2015, VA reported that VHA had established a working group to review this recommendation and also had created a database to collect and analyze aggregate data from AIB investigations into senior executive service (SES) employees. Based on an informal survey of its working group as well as its analysis of AIB data for SES employees, VA stated that central office oversight of the AIB process is not needed and that several systems already in place capture data on system-wide risks (e.g., sexual assault reporting, Issue Briefs, and National Center for Patient Safety Patient Safety Information System Program). Ultimately, VA stated that it could not justify the resources needed to implement this recommendation.
    Recommendation: To systematically gauge the extent to which deficiencies identified by individual AIBs may be occurring throughout VHA; and to maximize opportunities for sharing information across VHA to improve its overall operations, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish a process for sharing information about systemic changes, including policies and procedures implemented in response to the results of AIB investigations, which may have broader applicability throughout VHA.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with this recommendation and noted that it would explore any new processes for collecting and analyzing aggregate data from AIB investigations. In September 2015, VA reported that it had established a working group to review this recommendation. In addition, VA also had created a database to collect and analyze aggregate data from AIB investigations into senior executive service (SES) employees to identify trends and address deficiencies. Based on an informal survey of its working group and its analysis of AIB data for SES employees, VA stated that VISNs currently provide adequate oversight of the AIB process and notify VA central office when appropriate and that a comprehensive review of its AIB data for SES employees identified no system-wide issues. Ultimately, VA stated that it could not justify the resources needed to implement this recommendation.
    Director: Goldenkoff, Robert N
    Phone: (202)512-3000

    2 open recommendations
    including 1 priority recommendation
    Recommendation: To improve the Bureau's ability to control costs for the 2020 decennial and balance cost and quality, the Secretary of Commerce should direct the Under Secretary of the Economics and Statistics Administration, as well as the Director of the U.S. Census Bureau, to finalize how the Bureau will apply cost as an evaluation criterion for choosing among design alternatives for 2020 and ensure that all criteria are transparent, well documented, and consistently applied before alternatives are eliminated.

    Agency: Department of Commerce
    Status: Open

    Comments: Commerce neither agreed nor disagreed with this recommendation. According to the Census Bureau, each research and testing (R&T) project team was to develop a study plan outlining the goal of the project, the expected outcome, and the methodology to be used to arrive at data to inform trade off analysis and decision-making. To help ensure efficient use of resources for 2020 R&T projects, and that the conclusions reached by the projects were sound and provide decision makers with reliable findings, the Bureau planned to establish internal Scientific and Methodological Review Panels. These panels were to evaluate research designs, provide critical feedback and guidance to the research teams and assess the validity of any findings, conclusions and recommendations. In October 2015 the Bureau released an operational plan that described at a high level how cost was a consideration, but it did not lay out the criteria to be used. As of July 2017, we are following up with Census officials to obtain evidence that cost is being used as an evaluation criterion when choosing among design alternatives.
    Recommendation: GAO previously recommended that the Secretary of Commerce direct the Bureau to establish guidance, policies, and procedures for cost estimation that would meet best practice criteria. To help ensure that the Bureau produces a reliable and high-quality cost estimate for the 2020 Census, the Bureau should finalize guidance, policies, and procedures for cost estimation in accordance with best practices prior to developing the Bureau's initial 2020 life cycle cost estimate.

    Agency: Department of Commerce: Bureau of the Census
    Status: Open
    Priority recommendation

    Comments: Commerce neither agreed nor disagreed with this recommendation. In October 2015, the Bureau announced an estimate of its 2020 Census life-cycle cost. In our June 30, 2016 report (GAO-16-628), we assessed the Bureau's guidance, policies, and procedures underlying that estimate. We found that the Bureau's cost estimate partially met the characteristics of two best practices (comprehensive and accurate) described in the GAO Cost Guide and minimally met the other two (well-documented and credible). In addition, best practices state that a risk and uncertainty analysis should be performed to determine the level of risk associated with the cost estimate. The Bureau carried out such an analysis only for a portion of estimated costs for fiscal years 2018 to 2020, covering $4.6 billion. This amounts to about 37 percent of the $12.5 billion total estimated life-cycle cost, and less than one-half of the total estimated cost of the Bureau to comply with best practices for cost estimation. To fully implement this recommendation, the Bureau needs to implement specific controls over its cost estimation process for the 2020 Census, such as guidance that documents who is responsible for what and when, and what information flows where and when. As of July 2017, Bureau officials are currently gathering artifacts to support implementation of this recommendation.
    Director: Williamson, Randall B
    Phone: (202)512-3000

    8 open recommendations
    Recommendation: To help ensure that the military services' requirements for physician credentialing and privileging are consistent across the MHS, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Surgeons General of the military services to establish a DOD-wide process to identify and address existing inconsistencies between DOD's and the military services' physician credentialing and privileging requirements, including those inconsistencies we identified in this report.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To help ensure that the military services' requirements for physician credentialing and privileging are consistent across the MHS, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Surgeons General of the military services to establish a DOD-wide process to coordinate all current and future efforts to revise physician credentialing and privileging requirements.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to coordinate individual MTFs' efforts to establish mechanisms to collect and analyze data to evaluate physician performance and support performance assessments.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to clarify requirements for how MTFs document follow-up on peer recommendations, including who is responsible for documenting follow-up and where that documentation should be filed.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to clarify requirements for the information that physicians need to provide in their curriculum vitae (CV) so that MTFs can identify unaccounted for periods in practice history, as well as how MTFs should document explanations of any unaccounted for periods.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to establish requirements for MTFs to document significant events that occur during the review of a credentials file, including which types of significant events should be documented, who is responsible for documenting significant events, and where that documentation should be filed.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to establish a process to ensure that relevant information from the DPDB is documented in the credentials file.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To assure that MTFs are fully complying with DOD's and the military services' requirements for physician credentialing and privileging and implementing these requirements appropriately, the Secretary of Defense should direct the Surgeons General of the military services to establish and implement an oversight process to conduct reviews of a sample of credentials files to identify and address areas of noncompliance and incomplete documentation.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: Currie, Christopher
    Phone: (404)679-3000

    1 open recommendations
    Recommendation: In order to help build and maintain a national biosurveillance capability in a manner that accounts for the particular challenges and opportunities of reliance on state and local partnerships, we recommend the Homeland Security Council direct the National Security Staff to take the following action as part of its implementation of our previous recommendation for a national biosurveillance strategy: Ensure that the national biosurveillance strategy (1) incorporates a means to leverage existing efforts that support nonfederal biosurveillance capabilities, (2) considers challenges that nonfederal jurisdictions face in building and maintaining biosurveillance capabilities, and (3) includes a framework to develop a baseline and gap assessment of nonfederal jurisdictions' biosurveillance capabilities.

    Agency: Executive Office of the President: Homeland Security Council
    Status: Open

    Comments: In June 2010, GAO recommended a national biosurveillance strategy to provide a framework for building and maintaining a national biosurveillance capability. In October 2011, building on that recommendation, we called for such a strategy to address key challenges we identified in state and local biosurveillance by accounting for the need to leverage nonfederal resources. In July 2012, the White House released the National Strategy for Biosurveillance. A strategic implementation plan was to be published within 120 days of strategy issuance. The July 2012 strategy did not adequately address the issues we raised related to state and local biosurveillance and acknowledged but did not meaningfully address the need to leverage nonfederal resources. As of March 14, 2013 the implementation plan has not been released.
    Director: King, Kathleen M
    Phone: (202)512-5154

    2 open recommendations
    Recommendation: To develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, the Secretary of Health and Human Services should direct the Director of IHS to develop a written policy documenting how IHS evaluates need for the CHS program and disseminate it to area offices and CHS programs to ensure they understand how unfunded services data are used to estimate overall program needs.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In response to this recommendation, IHS reported in October 2015 that it was completing a comprehensive update of a policy chapter related to the Contract Health Services (CHS) Program (also called the Purchased/Referred Care Program). The agency indicated that this revised chapter would incorporate a written policy on how IHS evaluates need for the CHS program. It indicated that the chapter update had been under revision since December 20, 2012, with final approval anticipated in 2015. In July 2017, IHS indicated that the policy was still under development and would be issued to all IHS sites by September 30, 2017.
    Recommendation: To develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, the Secretary of Health and Human Services should direct the Director of IHS to provide written guidance to CHS programs on a process to use when funds are depleted and there is a continued need for services, and monitor to ensure that appropriate actions are taken.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In response to this recommendation, IHS reported in October 2015 that it developed and distributed Fund Management Standardization guidance to Area Offices to monitor compliance by federal Contract Health Services (CHS) program (also called the Purchased/Referred Care program) Service Units. Also, IHS issued standardized spending plan procedures to all Area Offices and Federally-operated programs. Also, it indicated that spending plan guidance would be included in an update of a policy chapter related to the CHS program. The agency indicated that this chapter had been under revision since December 20, 2012, with final approval anticipated in 2015. In July 2017, IHS indicated that the policy was still under development and would be issued to all IHS sites by September 30, 2017.
    Director: Kohn, Linda T
    Phone: (202)512-3000

    2 open recommendations
    Recommendation: As HHS implements its current and forthcoming efforts to make transparent price information available to consumers, HHS should determine the feasibility of making estimates of complete costs of health care services available to consumers through any of these efforts.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In May 2013, CMS released average inpatient hospital charge information for more than 3,000 hospitals that receive Medicare Inpatient Prospective Payment System payments for the 100 most frequently billed discharges using DRGs from FY2011 and corresponding average Medicare payments. Shortly thereafter CMS also released outpatient charges. In April 2014, CMS also released data on payments to physicians under Medicare part B. This represents an effort to provide price transparency, although these are not complete cost estimates according to our definition in this report. As of September 2015, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: As HHS implements its current and forthcoming efforts to make transparent price information available to consumers, HHS should determine, as appropriate, the next steps for making estimates of complete costs of health care services available to consumers.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of September 2015, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Trimble, David C
    Phone: (202)512-9338

    3 open recommendations
    including 1 priority recommendation
    Recommendation: To improve EPA's ability to oversee the states' implementation of the Safe Drinking Water Act and provide Congress and the public with more complete and accurate information on compliance, the Administrator of EPA should resume data verification audits to routinely evaluate the quality of selected drinking water data on health-based and monitoring violations that the states provide to EPA. These audits should also evaluate the quality of data on the enforcement actions that states and other primacy agencies have taken to correct violations.

    Agency: Environmental Protection Agency
    Status: Open
    Priority recommendation

    Comments: As of May 2017, EPA reported that it had not resumed its data verification audits due to budgetary constraints, but was continuing on-site file reviews to support efficient and effective state programs. EPA completed 5 file reviews in 2015, 7 in 2016, and was planning to complete 10 in 2017. According to EPA, budgetary constraints may affect its ability to reach this goal. According to the agency, EPA continues to focus on developing its Safe Drinking Water Information System (SDWIS) Prime database, which it claims will reduce state burden, support effective management and prioritization of resources, and will enhance data quality and support the possibility of building an electronic data verification protocol. EPA said it plans to have the system operational in 2018. In addition, EPA said that it continues to provide training sessions as well as identify best practices that file reviewers can use to enhance file review implementation. For 2017-2018, EPA plans to continue quarterly national training events. A July 2017 report by EPA's Office of the Inspector General concluded that limitations to EPA's oversight tools impede the agency's ability to conduct consistent oversight of the national drinking water program and reduce the reliability of its monitoring and reporting data. The Inspector General did not make any recommendations because it concluded the agency is taking steps to address the shortcomings. For example, according to the Inspector General's report, EPA released the Compliance Monitoring Data Portal in September 2016. EPA water officials said the portal will enable public water systems and laboratories to report drinking water data electronically to primacy agencies. Utah became the first state to use the portal in March 2017 and EPA staff anticipate that five additional states will begin using the portal by the end of 2017. EPA anticipates this system will lead to fewer reporting errors, improved data quality, and reduced time needed to report state data to EPA.
    Recommendation: To improve EPA's ability to oversee the states' implementation of the Safe Drinking Water Act and provide Congress and the public with more complete and accurate information on compliance, the Administrator of EPA should work with the states to establish a goal, or goals, for the completeness and accuracy of data on monitoring violations. In setting these goals, EPA may want to consider whether certain types of monitoring violations merit specific targets. For example, the agency may decide that a goal for the states to completely and accurately report when required monitoring was not done should differ from a goal for reporting when monitoring was done but not reported on time.

    Agency: Environmental Protection Agency
    Status: Open

    Comments: As of May 2017, EPA has not worked with states to establish a national goal for the quality of monitoring violations. EPA stated that, without the ability to conduct on-site data verifications using a statistically-based sample size, it is unable to derive a goal that would capture both completeness of state reporting to EPA and whether the states correctly assigned a violation for missed monitoring. EPA said that it intends to work with states to evaluate the establishment of a monitoring data quality goal once the new Safe Drinking Water Information System (SDWIS) NextGen data system has been developed and electronic data verification functions are incorporated into the system. In April 2015, EPA indicated that the agency intends to separate monitoring violations from reporting violations in the new SDWIS Primacy Agency (Prime) data system. According to EPA, this will enable the primacy agencies and EPA to better understand the nature of system violations and with the violations delineated in this manner, EPA will be able to consider developing goals for monitoring and reporting violations. As of May 2017, EPA is scheduled to have SDWIS Prime available for testing in September 2017 and available for state users at the end of March 2018. EPA will consider GAO's recommendation once SDWIS Prime is fully operational and it is able to better establish such a goal.
    Recommendation: To improve EPA's ability to oversee the states' implementation of the Safe Drinking Water Act and provide Congress and the public with more complete and accurate information on compliance, the Administrator of EPA should consider whether EPA's performance measures for community water systems could be constructed to more clearly communicate the aggregate public health risk posed by these systems' noncompliance with SDWA and progress in having those systems return to compliance in a timely manner.

    Agency: Environmental Protection Agency
    Status: Open

    Comments: In August 2017, EPA told GAO that it continues to use a variety of tools and resources to identify strategies that will enhance how the agency conveys to the public information on drinking water quality and potential health risks associated with exposure to contaminants. With regard to GAO's recommendation, EPA told us it had previously collaborated with the EPA Regional managers to identify language that would enhance the communication of aggregate public health risk to consumers in regards to community water system measures. EPA developed the "person month" measure because it describes the percentage of people served by community water system that receive drinking water that meets all health-based drinking water standards, accounting for the duration of violations that occurred. EPA piloted this measure in Fiscal Year 2007 as an indicator measure. In Fiscal Year 2008, the measure was elevated to a strategic plan measure with established targets. After receiving positive response regarding this measure, in Fiscal Year 2015, the agency developed a "person month" measure for tribal community water systems. According to the agency, EPA will continue to take comments on existing and future measures during its 5 year strategic plan reviews.
    Director: Mccool, Thomas J
    Phone: (202)512-8678

    1 open recommendations
    Recommendation: In developing legislation for a national reporting system for the biological laboratory community, Congress may wish to consider provisions for the agency it designates as responsible for the system to take into account the following in design and implementation: (1) including stakeholders in setting system goals; (2) assessing labs' organizational culture to guide design and implementation decisions; (3) making reporting voluntary, with open-reporting formats that allow workers to report events in their own words and that can be submitted by all workers in a variety of modes (Web or postal), with the option to report to either an internal or external entity; (4) incorporating strong reporter protections, data deidentification measures, and other incentives for reporting; (5) developing feedback mechanisms and an industry-level entity for disseminating safety data and safety recommendations across the lab community; and (6) ensuring ongoing monitoring and evaluation of the safety reporting system and safety culture.

    Agency: Congress
    Status: Open

    Comments: Congress has not taken action on this recommendation.
    Director: Williamson, Randall B
    Phone: (206)287-4860

    1 open recommendations
    Recommendation: To help DOD obtain reasonable assurance that all active and Reserve component servicemembers to whom the PDHRA requirement applies are provided the opportunity to have their health concerns identified, the Assistant Secretary of Defense for Health Affairs and the military services should take steps to ensure that PDHRA questionnaires are included in DOD's central repository for each of these servicemembers.

    Agency: Department of Defense
    Status: Open

    Comments: In its comments to this report, the Department of Defense (DOD) concurred with this recommendation. On October 2009, DOD's Force Health Protection and Response Office sent a memo to each of the military service Surgeons General emphasizing the need for the post-deployment health reassessment (PDHRA) to be offered to all service members who are eligible to complete the assessment. In 2010, DOD's noted that the services would work with the Armed Forces Health Surveillance Center (AFHSC) repository to ensure PDHRAs are submitted correctly, without transmission errors. DOD's 2011 case records showed that the Air Force and Army had developed data verification processes to ensure that AFHSC received PDHRAs. Further, the Defense Medical Data Center (DMDC) had planed to create a file consisting of the date of deployment for deployed personnel, and that the file would be available to the services in order to match DMDC with data from each of the service-specific systems, in accordance to requirements. In September 2011, although DMDC and the services had agreed to match rosters of deployed service members, there were still inconsistencies in deployment dates. In March 2012, DOD was still verifying data inconsistencies which, until resolved, leads to inaccurate reporting based on errors in the deployment dates.
    Director: Iritani, Katherine M
    Phone: (202)512-7059

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To meet its fiduciary responsibility of ensuring that section 1115 waivers are budget neutral, the Secretary of Health and Human services should better ensure that valid methods are used to demonstrate budget neutrality, by developing and implementing consistent criteria for consideration of section 1115 demonstration waiver proposals.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: HHS has generally disagreed with this recommendation. However, we have reiterated the need for increased attention to the fiscal responsibility in the approval of the section 1115 Medicaid demonstrations in subsequent 2008 and 2013 reports (GAO-08-87 and GAO-13-384). Although HHS has not issued a written budget neutrality policy as of October 2016, it has taken steps to change some aspects of methods states can use to determine budget neutrality and demonstration spending limits. The new methods are intended to result in more appropriate demonstration spending limits. For example, according to CMS officials, starting in May 2016, the agency began reducing the amount of accumulated savings that states can carryover when demonstrations are renewed, which was previously unlimited. We are continuing to monitor the effect of the recent changes. The recent changes did not address all of the questionable methods we have identifed in our reports.