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: As HHS implements its current and forthcoming efforts to make transparent price information available to consumers, HHS should determine the feasibility of making estimates of complete costs of health care services available to consumers through any of these efforts.

Agency: Department of Health and Human Services
Status: Open

Comments: In May 2013, CMS released average inpatient hospital charge information for more than 3,000 hospitals that receive Medicare Inpatient Prospective Payment System payments for the 100 most frequently billed discharges using DRGs from FY2011 and corresponding average Medicare payments. Shortly thereafter CMS also released outpatient charges. In April 2014, CMS also released data on payments to physicians under Medicare part B. This represents an effort to provide price transparency, although these are not complete cost estimates according to our definition in this report. As of September 2015, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.

Recommendation: As HHS implements its current and forthcoming efforts to make transparent price information available to consumers, HHS should determine, as appropriate, the next steps for making estimates of complete costs of health care services available to consumers.

Agency: Department of Health and Human Services
Status: Open

Comments: As of September 2015, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.

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 April 2020, there had been no legislation introduced to require HHS to improve the Medicaid demonstration review process. However, HHS has taken some action to address some aspects of GAO's recommendation. CMS established new policies that addressed certain problems GAO had identified and issued written guidance on the process and criteria used to approved states' proposed spending limits. Not all problems identified by GAO were addressed by the new CMS policy, thus legislation to require HHS to improve the Medicaid demonstration review process, as GAO recommended in January 2008, continues to be a viable matter for consideration.

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 April 2020, Congress had not passed legislation in response to our matter for congressional consideration.

Recommendation: To meet its fiduciary responsibility of ensuring that section 1115 waivers are budget neutral, the Secretary of Health and Human services should better ensure that valid methods are used to demonstrate budget neutrality, by developing and implementing consistent criteria for consideration of section 1115 demonstration waiver proposals.

Agency: Department of Health and Human Services
Status: Open
Priority recommendation

Comments: As of January 2020, the Department of Health and Human Services (HHS) had taken some action to address GAO's 2002 recommendation. In August 2018, HHS issued written guidance through a State Medicaid Directors Letter documenting four key changes it made in 2016 to its budget neutrality policy. These changes addressed some, but not all of the questionable methods GAO identified in its reports. To fully address this recommendation, HHS should also address these other questionable methods, such as setting demonstration spending limits based on hypothetical costs-what the state could have paid-rather than payments actually made by the state. GAO has found that the use of hypothetical costs has the potential to inflate spending limits and thus threatens budget neutrality of demonstrations