Recommendation: The Secretary of Energy should lead the development of a mechanism for interagency collaboration to determine roles and responsibilities for addressing priorities related to research on the health effects of low-dose radiation.

Agency: Department of Energy
Status: Open

Comments: In a July 2018 update, DOE stated that it believes that the White House Office of Science and Technology Policy's (OSTP) National Science and Technology Council (NSTC) is the appropriate entity to lead interagency collaboration and coordinate science and technology policy. According to DOE, OSTP intends to charter an interagency working group under the NSTC on a government-wide strategy related to research on the health effects of low-dose radiation. As of December 2019, OSTP had begun to address a related requirement under the American Innovation and Competitiveness Act to coordinate federal efforts related to radiation biology research and planned to release a report on this topic in early 2020. When we confirm what actions OSTP has taken to establish this working group, we will provide updated information.

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: As of March 2020, no legislative action had been identified that changes how PCHs are paid for inpatient services, as GAO suggested in February 2015. The 21st Century Cures Act-Pub. L. No. 114-255, ?16002, 130 Stat. 1033, 1325 (2016), 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. Until Medicare pays these cancer hospitals in a way that encourages greater efficiency, Medicare remains at risk for overspending.

Recommendation: To increase beneficiaries' awareness of providers' financial interest in a particular treatment, Congress should consider directing the Secretary of Health and Human Services to require providers who self-refer IMRT services to disclose to their patients that they have a financial interest in the service.

Agency: Congress
Status: Open

Comments: In August 2013, to increase beneficiaries' awareness of providers' financial interest in a particular treatment, we suggested that Congress should consider directing the Secretary of Health and Human Services to require providers who self-refer IMRT services to disclose to their patients that they have a financial interest in the service. As of June 2020, Congress has not implemented this suggestion.

Recommendation: The Administrator of CMS should insert a self-referral flag on its Medicare Part B claims form, require providers to indicate whether the IMRT service for which a provider bills Medicare is self-referred, and monitor the effects that self-referral has on costs and beneficiary treatment selection.

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

Comments: In August 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) insert a self-referral flag on its Medicare Part B claims form, require providers to indicate whether the intensity-modulated radiation therapy (IMRT) service for which a provider bills Medicare is self-referred, and monitor the effects that self-referral has on costs and beneficiary treatment selection. 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, would be complex to administer, and may have unintended consequences. 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 IMRT services and monitor the effects of self-referral. As of June 2020, CMS has not provided any additional information about actions it has taken to address this recommendation.

Recommendation: To ensure that EPA maximizes its limited resources and addresses the statutory, regulatory, and programmatic needs of EPA program offices and regions when IRIS toxicity assessments are not available, and once demand for the IRIS Program is determined, the EPA Administrator should direct the Deputy Administrator, in coordination with EPA's Science Advisor, to develop an agencywide strategy to address the unmet needs of EPA program offices and regions that includes, at a minimum: (1) coordination across EPA offices and with other federal research agencies to help identify and fill data gaps that preclude the agency from conducting IRIS toxicity assessments, and (2) guidance that describes alternative sources of toxicity information and when it would be appropriate to use them when IRIS values are not available, applicable, or current.

Agency: Environmental Protection Agency
Status: Open
Priority recommendation

Comments: As of February 2020, IRIS program officials indicated that they are building capacity for applying systematic review in chemical assessments. We reported in March 2019 that staff from the IRIS program were communicating more frequently with EPA program and regional offices about program and regional office needs and the IRIS program's ability to meet those needs. While ORD's newly-implemented survey process helps identify a limited number of the highest priority needs for program and regional offices, we also reported in March 2019 that program and regional officials told us that they still need far more chemical assessments than the IRIS program currently produces, and they do not have EPA-wide guidance on what sources to use when IRIS assessments are not available. One program office has developed its own prioritized list of sources for chemical assessments when IRIS assessments are not available, and other offices follow similar guidelines, though none officially. EPA leadership needs to provide documentation showing an agency-wide strategy that includes identifying data gaps and guidance on alternative sources of toxicity information when IRIS values are not available, applicable, or current.