Ryan White CARE Act:

Health Resources and Services Administration's Implementation of Certain Provisions Hampered by Lack of Timely and Accurate Information

GAO-09-1020: Published: Sep 29, 2009. Publicly Released: Sep 29, 2009.

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Under the CARE Act, funds are made available to assist over 530,000 individuals affected by HIV/AIDS. Grantees directly provide services to individuals (clients) or arrange with service providers to do so. The Department of Health and Human Services's (HHS), Health Resources and Services Administration (HRSA), which administers CARE Act programs, is required to cancel balances of grants that are unobligated after one year and redistribute amounts to grantees in need. HRSA began to collect client-level data in 2009. Under the CARE Act, states and territories receive grants for AIDS Drug Assistance Programs (ADAP), which provide HIV/AIDS drugs. GAO was asked to examine elements of the CARE Act. In this report, we review: (1) HRSA's implementation of the unobligated balance provisions, (2) HRSA's actions to collect client-level data, and (3) the status of ADAP waiting lists. GAO reviewed reports and agency documents and interviewed federal officials, officials from 13 state and 5 local health departments chosen based on location and number of cases, and other individuals knowledgeable about HIV/AIDS.

The lack of timely and accurate information reporting by grantees has delayed HRSA's distribution of certain grants and has placed at risk HRSA's ability to obligate these funds. The late submission of actual unobligated balances for the 2007 grant year delayed HRSA's ability to determine grantees' unobligated balances and redistribute these funds to other grantees. A number of grantees were late in their submissions. For example, 21 of the 56 metropolitan areas submitted their information beyond the date initially set by HRSA. Additionally, some grantees reported inaccurate unobligated balances, which required HRSA staff to correspond with grantees and request revised information, creating additional delays. HRSA is authorized to obligate fiscal year 2007 funds for a 3-year period and is at risk of losing the authority to make grants from these funds. HRSA officials said they have made changes to how they implement the unobligated provisions in an effort to avoid these issues in the future. HRSA has taken actions to collect client-level data by implementing a new data collection and reporting system. However, some grantees and service providers did not submit the initial reports by HRSA's deadline. HRSA set a July 31, 2009, submission deadline for grantees' initial reports, but 100 of 638 grantees did not meet this deadline. Client-level data includes information such as the dates clients were served, the types of services provided, and the clients' health status. HRSA has implemented a system to collect data on the number of unique clients from grantees and service providers that will allow HRSA to determine the services each client received and the outcomes of these services. In order for HRSA to collect this information, grantees and service providers must first collect the data using their own systems, and HRSA has provided technical and financial assistance so that they can develop these systems. For example, under a project initiated in 2009, HRSA awarded approximately $4 million to CARE Act grantees for the development of their own client-level data collection systems. The number of ADAPs with waiting lists and the number of individuals on those lists is increasing. In the first quarter of grant year 2008 (April 1, 2008, through June 30, 2008), 2 ADAPs had waiting lists with a total of 55 people on those lists; this grew to 3 ADAPs and a total of 112 people in the fourth quarter of the year, and increased to 4 ADAPs and 136 individuals in August 2009. Kentucky, Montana, Nebraska, and Wyoming were each maintaining a waiting list for ADAP services in August 2009; Nebraska had the largest number of individuals (71), and Wyoming had the smallest number (5). ADAP officials expressed concern that they will have to establish or expand waiting lists or implement other cost-control measures, such as limiting the number of drugs they make available.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: HRSA has provided reasons that Ryan White Part A and B grantees were unable to provide a timely and accurate accounting of their unobligated balances including: 1) Part A and B grantees must compile information for HRSA on their direct financial transactions and the transactions of their subcontractors. The grantees are often delayed by the subcontractors and therefore require additional time to complete a timely accounting of their total balances (direct balances and those of the subcontractors) on their federal financial report (FFR). Additionally, HRSA reports that it takes time for HRSA administrative staff to work with the grantees to reconcile their FFRs with HRSA's accounting of their drawdown requests with the HRSA payment management system. Often there were timing differences between those two systems which HRSA has recently sought to align in order to assist grantees with aligning these two systems. Finally, GAO reported that grantees were given extensions in the submission of their FFRs that contained the unobligated balance information. Due to these often lengthy extensions, HRSA was unable use the information they needed from the FFRs complete all of the steps necessary to meet their statutory requirements in regards to the grantees unobligated balance provisions. However, in July 2012, HRSA established that grantees would no longer be granted extensions for submission of their FFRs. Therefore, HRSA would be able to have all the information they needed from grantees within the timeframe necessary to meet the statutory requirements.

    Recommendation: To help ensure that HRSA is able to implement the unobligated balance provisions in a timely manner, and to obtain timely and accurate information on grantees' unobligated balances, the Secretary of HHS should instruct the administrator of HRSA to identify the causes of grantees' difficulties in providing a timely and accurate accounting of their unobligated balances.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: HRSA has taken steps to address two components of the unobligated balance finding in our report. First, we reported that grantees often asked for lengthy extensions in their federal financial report (FFR) submissions in order to obtain necessary information from their subcontractors which was needed for the FFR. HRSA granted these extensions even though they needed information from the FFR to complete their unobligated balance statutory requirements. HRSA issued a letter to grantees in July 2012 that ended all extensions for submission of grantees' FFRs, thereby allowing HRSA the time it needed to complete the statutory requirements. Second, HRSA stated that one of the causes of the grantees untimely unobligated balance submissions was the time it took for HRSA staff to reconcile the grantees' drawdown requests with the grantees accounting on their FFR. They also stated that their were timing differences between these two reports. HRSA has aligned the submission date for the FFR with the submission date for the payment management system to eliminate timing issues that could lead to significant discrepancies between HRSA's accounting of the grantees' funds and the grantees' accounting on the FFR that could affect the grantees' unobligated balances. HRSA also provided technical assistance webinars to Ryan White Part A and B grantees to explain these two changes and address other challenges they faced in regards to their unobligated balances.

    Recommendation: To help ensure that HRSA is able to implement the unobligated balance provisions in a timely manner, and to obtain timely and accurate information on grantees' unobligated balances, the Secretary of HHS should instruct the administrator of HRSA ensure that grantees adhere to deadlines for submission of their unobligated balances by developing steps to assist them in overcoming the causes of difficulties identified in accounting for unobligated balances.

    Agency Affected: Department of Health and Human Services


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