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entitled 'September 11: World Trade Center Health Programs Business 
Process Center Proposal and Subsequent Data Collection' which was 
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United States Government Accountability Office: 
Washington, DC 20548: 

December 3, 2010: 

The Honorable Frank Pallone, Jr. 
Subcommittee on Health: 
Committee on Energy and Commerce: 
House of Representatives: 

The Honorable Eliot L. Engel: 
House of Representatives: 

The Honorable Carolyn B. Maloney: 
House of Representatives: 

The Honorable Jerrold Nadler: 
House of Representatives: 

The Honorable Anthony D. Weiner: 
House of Representatives: 

Subject: September 11: World Trade Center Health Programs Business 
Process Center Proposal and Subsequent Data Collection: 

From the September 11, 2001, attack on the World Trade Center (WTC) 
through fiscal year 2010, approximately $475 million in federal funds 
was made available for screening, monitoring, or treating responders 
[Footnote 1] for illnesses and conditions--such as asthma and 
depression--related to the WTC disaster.[Footnote 2] Within the 
Department of Health and Human Services, the Centers for Disease 
Control and Prevention's (CDC) National Institute for Occupational 
Safety and Health (NIOSH) awards funds to and oversees the programs 
that provide screening, monitoring, and treatment services for 
responders to the WTC attack. The two largest programs, which we refer 
to here as the WTC health programs, are the New York City Fire 
Department's (FDNY) WTC Medical Monitoring and Treatment Program, and 
the New York/New Jersey (NY/NJ) WTC Consortium.[Footnote 3] These 
programs began as screening and monitoring programs, tracking the 
health status of responders related to the WTC disaster. In December 
2005, the Congress first appropriated funds that were specifically 
available for treatment programs for certain responders with health 
conditions related to the WTC disaster, and in fall 2006, NIOSH began 
awarding funds for outpatient and inpatient treatment. According to 
NIOSH, as of June 30, 2010, a total of about 44,000 responders had 
been screened by the WTC health programs; from July 1, 2009, to June 
30, 2010, about 23,000 were monitored and about 13,000 were treated. 
[Footnote 4] 

In 2007 we reported that NIOSH did not have a reliable estimate of the 
cost of providing monitoring and treatment services because, in part, 
it did not have actual cost data from the programs.[Footnote 5] In 
addition, a task force established by the Secretary of Health and 
Human Services to assess the WTC health programs found that the 
programs lacked financial accountability measures and that NIOSH 
needed to collect reliable data necessary for program management and 
planning for the future. In 2007, NIOSH proposed establishing a 
business process center (BPC) to, among other things, provide such 
data.[Footnote 6] In October 2007, CDC published a solicitation for 
the purpose of awarding a BPC contract, and in November it held a 
conference in New York City for interested parties. However, on 
December 13, 2007, CDC canceled the solicitation.[Footnote 7] 

In light of issues raised about NIOSH's data collection efforts and 
the cancellation of the BPC solicitation, you requested that we report 
on NIOSH's efforts to collect data from the WTC health programs 
without the BPC. In this report, we describe (1) the purpose of 
NIOSH's proposed BPC with regard to data collection from the WTC 
health programs, and (2) any action NIOSH has taken since the 
cancellation of the BPC solicitation in an effort to improve data 
collection. To conduct this work, we interviewed NIOSH officials and 
reviewed relevant documentation, including the solicitation for the 
BPC and information collected by NIOSH as a part of its oversight of 
the WTC health programs. 

We conducted this performance audit in November 2010 in accordance 
with generally accepted government auditing standards. Those standards 
require that we plan and perform the audit to obtain sufficient, 
appropriate evidence to provide a reasonable basis for our findings 
and conclusions based on our audit objectives. We believe that the 
evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. 

The Proposed BPC Was Intended to Provide NIOSH with a Single Source of 
Detailed Data on Responders, Health Services, and Costs: 

NIOSH's proposed BPC was intended to provide an efficient mechanism 
for collecting uniform data across the WTC health programs on 
responders' health conditions, health services provided by the 
programs, and costs of the programs. According to a NIOSH official 
involved in administering the WTC health programs, the BPC would have 
given NIOSH access to a single source of claims information from the 
WTC health programs. The official told us that this claims information 
would have documented responders' health conditions, the procedures 
and medications used to care for responders, and the programs' costs. 
That is, claims data would have provided information about a specific 
patient encounter, including the individual responder's health 
condition, age, and geographic location; the array of services 
provided to the responder during the encounter, such as a physical 
examination or X-ray; and the costs of the encounter. The NIOSH 
official said that such information would have helped the agency 
identify ways to improve the programs' effectiveness and predict 
future costs. For example, claims data on responders' health 
conditions would have indicated the level of need for specific types 
of services. The NIOSH official also said that the claims information 
would have supported program oversight by, for example, providing 
verification that a specific program service was provided to an 

NIOSH Has Taken Action to Gather More Detailed Information about 
Responders' Health Conditions: 

Since cancellation of the BPC solicitation, NIOSH has taken action to 
gather more detailed information about responders' health conditions. 
As we reported in July 2007, NIOSH has required the WTC health 
programs to submit quarterly reports containing detailed demographic, 
service utilization, and cost information; the programs began 
submitting these reports in early 2007. The information in the 
quarterly reports included the total numbers of responders monitored 
and treated; for each of five diagnostic categories, the total number 
of responders monitored and treated;[Footnote 8] the total number of 
treatment services by service category;[Footnote 9] and total 
outpatient monitoring and treatment costs and inpatient treatment 
costs. According to a NIOSH official, in July 2009, NIOSH began to 
require the programs to provide more detailed diagnostic information. 
For example, the programs were required to report the number of 
responders with certain lower airway conditions, such as asthma and 
chronic obstructive pulmonary disease. The NIOSH official told us that 
the agency is also considering requiring the programs to provide more 
detailed cost information, such as identifying costs by physical and 
mental health services. He added that more detailed cost information 
would be useful for understanding which types of services are most 
costly and for identifying cost trends, which could help NIOSH 
anticipate future program needs. 

A NIOSH official told us that the type of information that the agency 
currently collects from the programs is not as detailed as the claims 
data that would have been processed by the BPC envisioned in 2007. 
NIOSH does not have access to the types of information associated with 
a specific patient encounter, such as details about the responder's 
health, specific services the responder received, and the cost of 
providing services to a responder during that encounter. Therefore, 
NIOSH cannot perform the types of program effectiveness and cost 
analyses that it would have expected to perform with claims data 
processed by the BPC. 

Agency Comments: 

The Department of Health and Human Services reviewed a draft of this 
report and provided technical comments, which we incorporated as 

We are sending copies of this report to the Secretary of Health and 
Human Services. In addition, the report will also be available at no 
charge on the GAO Web site at [hyperlink,]. 

If you or your staffs have any questions regarding this report, please 
contact me at (202) 512-7114 or Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major 
contributions to this report are listed in enclosure I. 

Signed by: 

Cynthia A. Bascetta: 
Director, Health Care: 

[End of section] 

Enclosures I: GAO Contact and Staff Acknowledgments: 


Cynthia A. Bascetta at (202) 512-7114 or 


In addition to the contact named above, key contributors to this 
report were Helene F. Toiv, Assistant Director; George Bogart; Hernan 
Bozzolo; Anne Dievler; Roseanne Price; and Christina E. Ritchie. 

[End of section] 


[1] In this report, "responders" refers to anyone involved in rescue, 
recovery, or cleanup activities at or near the vicinity of the WTC or 
the Staten Island site, the landfill that is the off-site location of 
the WTC recovery operation. Responders included New York City Fire 
Department (FDNY) personnel, federal government personnel, and other 
government and private-sector workers and volunteers from New York and 

[2] See Congressional Research Service, Comparison of the Current 
World Trade Center Medical Monitoring and Treatment Program and the 
World Trade Center Health Program Proposed by Title I of H.R. 847, 
R41292 (Washington D.C.: Oct. 15, 2010), and GAO, September 11: HHS 
Needs to Develop a Plan That Incorporates Lessons from the Responder 
Health Programs, [hyperlink,] 
(Washington, D.C.: May 30, 2008). 

[3] NIOSH awards funds to the FDNY WTC program and the NY/NJ WTC 
Consortium through cooperative agreements. The NY/NJ WTC Consortium 
consists of five clinical centers in the NY/NJ area. The other WTC 
programs to which NIOSH has awarded funds include the National 
Responder Health Program, for responders residing outside the New York 
City area, and the Police Organization Providing Peer Assistance 
(POPPA) program and Project COPE, which provide mental health services 
to New York City Police Department employees and their family members. 
See GAO, September 11: HHS Needs to Ensure the Availability of Health 
Screening and Monitoring for All Responders, GAO-07-892 (Washington, 
D.C.: July 23, 2007) and GAO-08-610. 

[4] NIOSH reports current data on the numbers of responders screened, 
monitored, and treated on its Web site: [hyperlink,] (accessed Oct. 
5, 2010). These data include the numbers of responders served by the 
National Responder Health Program. 

[5] See [hyperlink,]. 

[6] Other responsibilities identified for the BPC included providing a 
nationwide pharmacy benefit plan for program enrollees and 
establishing and managing a national network of health care providers 
to provide monitoring and treatment to responders outside the New York 
City metropolitan area. 

[7] During a March 2008 congressional hearing, the director of NIOSH 
provided reasons for canceling the solicitation, including the 
following: "(1) It was not clear that funding was available to support 
the Performance Work Statement (PWS); (2) The Technical Requirements 
in the PWS required clarification; (3) The interest from industry had 
been limited--attendance at a pre-proposal conference was unusually 
small for a procurement of this size..." 

[8] The five diagnostic categories were upper airway, lower airway, 
gastrointestinal, musculoskeletal, and mental health. 

[9] The service categories included, for example, internal medicine, 
pulmonology, and psychiatry. 

[End of section] 

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