World Trade Center Health Program: Quality Assurance Program Should Include Monitoring of Access to Health Services
Fast Facts
The World Trade Center Health Program provides health services to eligible responders and survivors for conditions related to the Sept. 11 attacks.
Timely access is an important part of quality health care, but people have reported delays accessing program services outside the New York City area. We reviewed whether the program assesses the timeliness of access to these services.
The program's quality assurance committee is responsible for monitoring program activities. But it hasn't assessed this issue, in part because the program has not made timely access an explicit strategic priority—which we recommended addressing.
Highlights
What GAO Found
The World Trade Center Health Program, administered by the National Institute for Occupational Safety and Health (NIOSH), provides health services to eligible responders and survivors of the September 11, 2001, attacks at no cost. NIOSH contracts with clinics in the New York City area and a Nationwide Provider Network (NPN) to provide health services to these individuals—known as members. Spending on health services by the program increased by about 85 percent from fiscal year 2016 through 2021. (See figure.) Clinics that serve responders in the New York City area accounted for the majority of health services spending. Clinics that serve survivors in the New York City area and through the NPN accounted for a growing share of total spending over the time period reviewed.
World Trade Center Health Program Spending on Health Services, Fiscal Years 2016 through 2021
The World Trade Center Health Program Quality Assurance Committee is comprised of senior program leadership. It was established to develop quality assurance objectives, formulate plans to achieve those objectives, and monitor related activities throughout the program. This is to be accomplished, for example, by recommending the development of performance metrics. In addition, NIOSH developed strategic priorities for the program. According to officials, NIOSH also applies resources, including quality assurance staff, to support these priorities.
Timely access to health services is an important component of quality health care. However, NIOSH has not specified ensuring timely access among the program's strategic priorities. In addition, the Quality Assurance Committee has not assessed the extent to which members have timely access to health services through the NPN because there are no quality assurance metrics for this. However, information previously collected by the NPN contractor, which was not provided to the Quality Assurance Committee, indicates there were potential problems with the timeliness of members' access to health services. Absent prioritizing timely access to health services, establishing metrics, and reviewing metric data, there is increased risk that reported delays in some members' access to NPN-provided health services may continue and negatively affect those members' morbidity, mortality, and quality of life.
Why GAO Did This Study
The World Trade Center Health Program provides health services, such as monitoring and treatment for conditions related to the September 11, 2001, attacks, through clinics in the New York City area and the NPN. The program is required to ensure reasonable access to health services through the NPN. However, program stakeholders have reported delays with members' access to these services.
The James Zadroga 9/11 Health and Compensation Reauthorization Act included a provision for GAO to review the World Trade Center Health Program. This report examines the extent to which (1) program spending on health services increased, and (2) NIOSH's quality assurance efforts included assessing the timeliness of access to health services for members through the NPN. GAO analyzed data on claims paid by the program. GAO also interviewed NIOSH officials and reviewed program documents on its quality assurance governance structure and strategic priorities.
Recommendations
GAO is making three recommendations to NIOSH: (1) add ensuring timely access to health services as a program strategic priority, (2) establish metrics for assessing the timeliness of access to health services through the NPN, and (3) ensure that the Quality Assurance Committee review metric data. The agency concurred with our recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| National Institute for Occupational Safety and Health | The Director of NIOSH should update the WTCHP Quality Assurance Plan's strategic priorities to include ensuring timely access to the five types of WTCHP health services and update program activities to align with this priority. (Recommendation 1) |
World Trade Center Health Program (WTHCP) officials have updated the Quality Assurance Plan's strategic priorities to include timely access to WTCHP health services and aligned program activities accordingly. In January 2023, HHS stated that the agency had hired a consultant group to assist with the Program's annual strategic planning, including to develop a strategic priority on ensuring timely access to WTCHP health services. In January 2024, HHS provided a copy of the March 2023 version of the WTCHP's strategic plan that included a goal to "provide quality and timely health care," under the strategic priority on "Excellence in Program Services." Subsequently, the WTCHP updated several of its contracts to align its vendors' activities with this new strategic priority and HHS stated the program will be similarly updating other contracts in the future. For example, in January 2025, HHS issued a solicitation to administer a newly re-structured Nationwide Provider Network (NPN) that included a requirement for the contractor to ensure that the network has the capacity to provide members timely access to the health services they are eligible to receive (which would include the five types of WTCHP health services). This is to be done by, among other things, assessing the time between scheduling and attending an appointment for each provider type within the network. The WTCHP also awarded another new contract with a performance start date of May 2026, specifically for case management and other member support services outside of the New York metropolitan area. The contract requires, for example, minimum outreach attempts to schedule initial health evaluations and monitoring exams for new members. Finally, the WTCHP has implemented similar minimum outreach requirements for the Clinical Centers of Excellence (CCE) for survivor members living in the New York Metropolitan area. In September 2026, HHS indicated that it plans to update activities for the CCEs that provide health services to other members living within the New York metropolitan area to align with this strategic goal as well, when contracts for those centers are next solicited in 2030. Based on these actions and plans, we are closing this recommendation as implemented.
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| National Institute for Occupational Safety and Health | The Director of NIOSH should establish quality assurance metrics related to the timeliness with which members can access WTCHP health services provided through the Nationwide Provider Network, and as appropriate the Clinical Centers of Excellence. Such metrics should account for the five types of WTCHP health services and include wait time standards and benchmarks. (Recommendation 2) |
WTCHP officials have taken initial steps to develop quality assurance metrics on members' timely access to WTCHP health services. HHS indicated that WTCHP officials had assessed other federal payer approaches to measuring wait times and was collaborating with the NPN and CCE to identify a suitable approach for the program. Specifically, HHS stated that WTCHP officials sent the NPN and CCEs a questionnaire in the summer of 2023 to assess how the clinics facilitate timely access to care for members, to understand how the clinics track appointment availability and identify issues with such timely access. In September 2025, HHS stated that WTCHP officials had sent the NPN and CCEs a second questionnaire in March 2025 to better understand appointment scheduling. They said the results underscore challenges with identifying a standardized, viable approach to collecting timeliness data across the program, but timeliness metrics, standards, and benchmarks were still under development as the program works toward resolving such challenges. In August 2026, HHS provided us with preliminary metrics, which reflected an approach that may enable the program to monitor systemwide timely access to care in a data-driven way. We will continue to track the program's actions to establish quality assurance metrics related to members' timely access to WTCHP health services.
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| National Institute for Occupational Safety and Health | The Director of NIOSH should ensure that the WTCHP Quality Assurance Committee review data on the timeliness with which members can access WTCHP health services provided through the Nationwide Provider Network, and as appropriate the Clinical Centers of Excellence, on at least an annual basis to identify and take steps to address any needed improvements. At a minimum, this should include reviewing the data on the quality assurance metrics related to access to care for the five types of WTCHP health services after they are established. (Recommendation 3) |
In January 2023 and January 2024, HHS shared information on the WTCHP Quality Assurance Committee's role in the development of quality assurance metrics on members' timely access to the five types of WTCHP health services. Specifically, the committee met in August 2022 to begin discussing potential metrics. During the June 2023 Quality Assurance Committee meeting, staff from the program's Quality Management & Program Evaluation Unit provided an update on the steps being taken to develop such metrics. According to HHS, the committee endorsed the planned next steps for developing metrics on timely access to health services. Additionally, in January 2024, HHS shared a committee meeting agenda template that includes a standing item on updates related to our recommendation. According to HHS, staff from the Quality Management & Program Evaluation Unit plan to use this to provide quarterly updates to the committee on activities related to assessing timely access to care. In September 2025, HHS said that it was continuing to keep the Quality Assurance Committee informed about the program's ongoing efforts related to developing timeliness metrics and other ongoing efforts related to ensuring timely access to care. In August 2026, HHS stated that the program was working to finalize the metrics it provided in response to recommendation 2 and exploring the feasibility of integrating related monitoring through existing oversight mechanisms such as semi-annual reports already being submitted by the NPN and CCEs. We will continue to track the program's actions to establish quality assurance metrics related to members' timely access to WTCHP health services, and then, once developed, the Quality Assurance Committee's actions to review the results of those metrics and take any needed actions.
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