Recommendation: The Secretary of VA should direct GEC leadership to develop measurable goals for its efforts to address key long-term care challenges: workforce shortages, geographic alignment of care, and difficulty meeting veterans' needs for specialty care. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of VA should direct GEC leadership to set time frames for and implement a consistent GEC structure at the VAMC level. (Recommendation 2)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of VA should direct GEC leadership to set time frames for and implement a VAMC-wide standardization of the tool for assessing the noninstitutional program needs of veterans. (Recommendation 3)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Administrator of ACL should take steps to better centralize access to and promote awareness of information on promising practices or other useful information pertinent to serving rural older adults.

Agency: Department of Health and Human Services: Administration for Community Living
Status: Open

Comments: HHS agreed with this recommendation, stating that it would encourage its resource centers to identify promising practices and other information specific to rural communities so that these resources would be searchable. In December 2019, ACL stated that it would continue to list all resource centers on its website so that anyone can find resources specific to any topic funded by ACL. The agency also noted that it would begin implementation of this action with new resource centers funded with FY 2020 appropriations. GAO continues to encourage ACL to centralize access to information pertinent to rural older adults by making it easily searchable across these websites or compiling it in other ways and promoting awareness of this information.

Recommendation: The Administrator of CMS should subject accessories essential to the group 3 power wheelchairs in the permanent DMEPOS program to prior authorization. (Recommendation 1)

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

Comments: In August 2018, the Department of Health and Human Services reported that it concurs with this recommendation and that CMS is exploring available options to subject accessories essential to the group 3 power wheelchairs in the permanent DMEPOS program to prior authorization. As of February 2020, HHS officials have not informed us of any actions taken to implement this recommendation. We will update the status of this recommendation when we receive additional information

Recommendation: The Administrator of CMS should take steps, based on results from evaluations, to continue prior authorization. These steps could include: (1) resuming the paused home health services demonstration; (2) extending current demonstrations; or, (3) identifying new opportunities for expanding prior authorization to additional items and services with high unnecessary utilization and high improper payment rates. (Recommendation 2)

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

Comments: In August 2018, the Department of Health and Human Services reported that it concurs with this recommendation. CMS has recently taken steps to evaluate and continue its prior authorization programs. In June 2019, CMS issued a final report on the independent evaluation of the non-emergency hyperbaric oxygen therapy demonstration. While the agency does not plan to conduct additional demonstrations on this service, CMS officials reported in December 2019 that the agency may consider this service for the new prior authorization process for certain hospital outpatient department services, established in a 2019 final rule. In April 2019, CMS issued a Federal Register notice that added 12 items-seven power wheelchairs and five pressure reducing support surfaces-to its required prior authorization list for the permanent program. CMS officials said in December 2019 that the agency was in the process of determining cost savings from this action and that additional items would be added to the list in early 2020. CMS resumed the home health services demonstration with changes in one state in June 2019 and in another state in September 2019. The agency plans to extend the demonstration to three additional states in 2020. In September 2019, CMS extended the repetitive scheduled non-emergency ambulance service demonstration for 1 year, through November 2020. GAO will continue to monitor issued agency guidance on the home health services demonstration and to evaluate additional steps CMS takes to evaluate and continue prior authorization in Medicare, such as determining cost savings from its actions and identifying new opportunities for prior authorization.

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: In March 2019, HHS included in its fiscal year 2020 budget a legislative proposal to extend Medicare coverage to disposable devices that could potentially substitute for DME in treating and managing diabetes. As of March 2020, CMS has not provided documentation of the evaluation of possible costs and savings that we recommended and that we believe underpins the legislative proposal. We will review this documentation once provided.

Recommendation: Depending on the outcome of the litigation, the Secretary of Labor should take steps to ensure the agency will be positioned to conduct a meaningful retrospective review consistent with the Executive Order at an appropriate time. These steps should be taken in consultation with the Centers for Medicare & Medicaid Services, and could include, for example, identifying metrics that could be used to evaluate the rule, and implementing a plan to gather and analyze the necessary data.

Agency: Department of Labor
Status: Open

Comments: The Department of Labor's Wage and Hour Division (WHD) agreed with this recommendation and reported that it is working to develop data collection plans and explore a potential evaluation that is focused on the Home Care Rule. As part of this effort, WHD noted that it will continue to work with HHS and other federal partners. In FY16, WHD reported that such an evaluation of how stakeholders and affected industries have responded to the rule would be beneficial. However, litigation has delayed implementation and enforcement of the rule significantly, and WHD believes an evaluation at this stage would be premature and would be unlikely to fully and accurately capture stakeholders' responses to the rule and the resulting impacts. Delaying the evaluation would allow WHD to monitor the results of its own investigations and the effects of ongoing compliance assistance, both of which would be extremely difficult to measure at this early stage. In 2017, WHD reported that it will continue to monitor early implementation to determine the appropriate start for any evaluation and lay the groundwork for future assessment, including a plan for how to identify data that would inform such as an assessment. In 2018, WHD reported that it is too early in the implementation phase of the rule to conduct an evaluation of the rule's impact. The Department and WHD continue to engage with HHS to understand stakeholders' responses to the rule. WHD also continues to lay the groundwork for any future assessment by working to identify data sources that would inform such as an assessment.