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    Subject Term: "Health care cost control"

    8 publications with a total of 15 open recommendations including 1 priority recommendation
    Director: John E. Dicken
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: In implementing the age and gender adjustment, the Commissioner of Internal Revenue should consider taking steps to mitigate the limitations of the BCBS Standard plan premium cost data--such as by combining data from multiple FEHBP plans. If combining the costs of plans with different benefit structures, the Commissioner should consider whether an appropriate actuarial adjustment should be used. If the Commissioner interprets that the statute does not provide the flexibility to mitigate the limitations of the BCBS Standard plan premium cost data by combining data from multiple sources or by other means, the Commissioner should seek that authority from Congress.

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

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

    1 open recommendations
    Recommendation: The Administrator of CMS should evaluate the possible costs and savings of using disposable devices that could potentially substitute for DME, including options for benefit categories and payment methodologies that could be used to cover these substitutes, and, if appropriate, seek legislative authority to cover these devices.

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

    Comments: As of November 2017, the Department of Health and Human Services (HHS) has not taken any steps to implement this recommendation. According to HHS, conducting such a study is premature because only Congress has the authority to create new benefit categories and payment systems, and additional information on potential substitutes is needed. However, while congressional action may be required for Medicare to cover some of the potential disposable DME substitutes we identified, GAO continues to believe that without conducting a study to identify the potential costs and benefits of covering such devices, CMS will lack the necessary clinical and cost information to determine if it would be beneficial to reassess clinical current statutory and regulatory coverage rules. In other instances, CMS has used the national and local coverage determination processes to establish clinically based policies related to DME. Moreover, CMS is uniquely positioned to consider the extent to which coverage of any clinically appropriate substitutes would benefit the federal government and beneficiaries.
    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: Katherine Iritani
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To improve consistency in CMS oversight of federal spending under section 1115 demonstrations, the Secretary of Health and Human Services should require the Administrator of CMS to develop and document standard operating procedures for monitoring spending under demonstrations that (1) require setting reporting requirements for states that provide CMS the data elements needed for CMS to assess compliance with demonstration spending limits; (2) require consistent enforcement of states' compliance with financial reporting requirements; and (3) require consistent tracking of the amount of unspent funds under demonstration spending limits.

    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 improve consistency in CMS oversight of federal spending under section 1115 demonstrations, the Secretary of Health and Human Services should require the Administrator of CMS to issue formal guidance on the revised budget neutrality policy, including information on how the policy will be applied.

    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: James Cosgrove
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: In order to prevent the shift of services from physician offices to HOPDs from increasing costs for the Medicare program and beneficiaries, Congress should consider directing the Secretary of HHS to equalize payment rates between settings for E/M office visits--and other services that the Secretary deems appropriate--and to return the associated savings to the Medicare program.

    Agency: Congress
    Status: Open

    Comments: When we determine what steps the Congress has taken, we will provide updated information.
    Director: King, Kathleen M
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: In order to promote greater use of effective prepayment edits and better ensure proper payment, and to promote implementation of effective edits based on national policies, the CMS Administrator should develop written procedures to provide guidance to agency staff on all steps in the processes for developing and implementing edits based on national policies, including (1) time frames for taking corrective actions, (2) methods for assessing the effects of corrective actions, and (3) procedures for ensuring consideration of automated edits whenever possible, including for all existing NCDs and other national policies.

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

    Comments: HHS concurred with this recommendation. CMS developed written procedures in November 2012 to provide guidance to agency staff on procedures for ensuring consideration of automated edits whenever possible, as GAO recommended in November 2012, but these procedures do not include several key elements of GAO's recommendation. For example, the written procedures do not include time frames for making decisions on whether an edit will be developed for all existing National Coverage Determinations (NCD) and national policies. The written procedures also do not include requirements for methods to assess the effects of corrective actions taken. Implementing a comprehensive written process for developing edits for national policies could help ensure that edits are implemented whenever possible to reduce improper payments. As of September 2017, CMS had not provided us updated documentation that addressed these aspects of our recommendation. Once received, we will review the information and update this recommendation accordingly.
    Director: Cosgrove, James C
    Phone: (202)512-7029

    2 open recommendations
    Recommendation: Congress may wish to consider reducing home oxygen payment rates to better align them with home oxygen suppliers' costs.

    Agency: Congress
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To establish rates that more accurately reflect the distinct costs of providing each type of home oxygen equipment, the Administrator of CMS should restructure Medicare's home oxygen payment methodology. This should include removing the payment for portable oxygen refills from that for stationary equipment and paying for refills only for the equipment types that require them.

    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: Iritani, Katherine
    Phone: (212) 512-3000

    2 open recommendations
    Recommendation: Congress may wish to consider requiring increased attention to fiscal responsibility in the approval of section 1115 Medicaid demonstrations by requiring the Secretary of HHS to improve the demonstration review process through steps such as (1) clarifying criteria for reviewing and approving states' proposed spending limits, (2) better ensuring that valid methods are used to demonstrate budget neutrality, and (3) documenting and making public material explaining the basis for any approvals.

    Agency: Congress
    Status: Open

    Comments: As of July 2015, no legislation on this topic had been passed, although at least one bill had been introduced in Congress that would make budget neutrality a statutory requirement for Medicaid demonstrations.The House Energy and Commerce Committee held a hearing in June 2015 examining HHS's approval of spending under Medicaid demonstrations. In addition, the House Oversight and Government Reform and House Energy and Commerce Committees had sent letters to the Administration inquiring as to how HHS was responding to GAO findings and recommendations to improve the process and methods used to set demonstration spending limits.
    Recommendation: Congress may wish to consider addressing whether demonstrations that allow states to operate public managed care organizations and retain excess revenue to support programs previously funded by the state--including the Vermont demonstration--are within the scope of the Secretary of HHS's authority under section 1115 of the Social Security Act.

    Agency: Congress
    Status: Open

    Comments: As of July 2015, Congress had not passed legislation in response to our matter for congressional consideration.