Recommendation: As MHS governing bodies conduct their recurring reviews of quality measures selected for MHS's Core Dashboard and Purchased Care Dashboards, the Assistant Secretary of Defense for Health Affairs should direct those bodies to prioritize, as appropriate, the selection of measures that apply to both direct and purchased care at the provider level and that expand the range of quality measure types and medical conditions that are assessed. (Recommendation 1)

Agency: Department of Defense: Office of the Assistant Secretary of Defense (Health Affairs)
Status: Open

Comments: As of January 2020, DOD officials described proposed actions to address key elements of our recommendation. Specifically, DOD officials described compiling a comprehensive library of existing inpatient and outpatient quality measures for both direct and purchased care; categorizing those measures by type and medical condition; and identifying 8 measures that are common across direct and purchased care. DOD stated it is considering expanding those 8 common measures to 12 measures. The new measures would cover three cancer screening measures and an additional inpatient satisfaction measure. However, DOD officials noted these 12 measures are not reported at the provider level for purchased care given current contract reporting requirements and would require contract modifications. DOD officials also said they are participating in an interagency partnership to use a common set of quality measures across federal programs, including under the Department of Veterans Affairs. Once those quality measures are determined, DOD may expand the range of quality measures common across direct and purchased care to be consistent with other federal programs. We will keep this recommendation open until DOD provides additional information on actions taken to select and expand quality measures across direct and purchased care.

Recommendation: The Assistant Secretary of Defense for Health Affairs should establish, as appropriate, performance standards related to the Purchased Care Dashboard measures that are consistent with the MHS's performance standards for direct care; ensure they are applied to individual purchased care providers; and take steps, such as amending its managed care support contracts, if necessary, to require corrective actions to be taken when providers do not meet those standards. (Recommendation 2)

Agency: Department of Defense: Office of the Assistant Secretary of Defense (Health Affairs)
Status: Open

Comments: As of January 2020, DOD officials said that once a common set of quality measures is adopted to the extent possible across direct and purchased care (as discussed in Recommendation 1), DOD plans to establish consistent performance standards applied to individual providers and plans to develop processes to issue corrective actions for individual direct and purchased care providers who do not consistently meet established standards. We will update this recommendation as DOD provides progress updates on the implementation of these plans.

Recommendation: To improve RRB's ability to make accurate disability benefit eligibility determinations, including CDRs, and to decrease the potential for making improper payments, Congress should consider granting RRB access to the Department of Health and Human Services' quarterly earnings information from the National Directory of New Hires database. (Matter for Consideration 1)

Agency: Congress
Status: Open

Comments: As of March 2020, no legislation has been enacted resulting from this matter to Congress. RRB's (the Board) fiscal year 2020 budget proposal included a legislative proposal to provide the Board access to the NDNH. Although the Board reported that the resulting proposed legislation drafted by HHS - the entity that maintains the NDNH - would, if enacted, provide access to the NDNH, the Board opposed the proposal in part because it would not waive associated fees to access the NDNH, and concluded access to the NDNH would not be cost-effective. In January 2020, the Board informed GAO it is not currently seeking legislation to gain access to the NDNH, resulting in the Board continuing to use earnings data that may be outdated in its continuing disability reviews, but that it may seek access in the future.

Recommendation: To enhance RRB's ability to manage and oversee its CDR program, RRB should routinely compile and analyze CDR program data, such as the number of cases selected for review, the number of beneficiaries in each medical improvement category, outcomes, and the costs and benefits of conducting CDRs, to improve program oversight. (Recommendation 3)

Agency: Railroad Retirement Board
Status: Open

Comments: RRB agreed with this recommendation. In June 2020, RRB reported that its Program Evaluation and Management Services (PEMS) section will compile and analyze all relevant CDR program case and cost data to better oversee CDRs. RRB said that its first analysis would cover CDR's adjudicated from April 2019 through September 2020; as of June 2020 they had adjudicated 107 CDR cases. In addition, RRB reported that its monthly reporting on CDRs to the Director of Disability includes information on the type of CDR completed, the medical improvement category for medical CDR, and the disposition of the CDR. In August 2018, the agency had reported that it began reporting in October 2017 weekly pending CDR type action cases to the Director of Programs, and that it had begun tracking CDR reason codes for each medical improvement category. To close this recommendation, RRB will need to include an analysis of the costs and benefits of conducting CDRs, including any overpayments or underpayments processed, and share its complete analysis of CDRs through September 2020 after it is completed. At that point GAO will review the analysis and decide if it provides a sufficient bases for program oversight.