Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, consistently collect complete and accurate information about the quality of available civilian health care in proximity to its MTFs (such as ratings from the Centers for Medicare and Medicaid Services and perceptions from MTF officials who regularly coordinate with civilian providers, among other means) and assess that information to inform recommendations for future MTF restructuring decisions. (Recommendation 1)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. In its response, the department described its planned implementation steps, such as publishing measures it may use for assessing available civilian health care. We will continue to monitor the status of the measures and any other actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, consistently collect complete and accurate information about the extent to which current health care providers within the TRICARE networks meet access-to-care standards, and assess that information to inform recommendations on future MTF restructuring decisions. (Recommendation 2)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. The department noted actions underway and planned to implement it, including a centralized appointment booking system and monitoring access to care as MTFs restructure. We will continue to monitor the status of this effort and any other actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, consistently collect complete and accurate information about the extent to which non-network civilian health care providers that could be incorporated into the TRICARE network meet access-to-care standards in terms of drive time, and assess that information to inform recommendations on future MTF restructuring decisions. (Recommendation 3)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation, and described planned steps to implement it for future MTF restructuring decisions. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, conducts a sensitivity analysis of the relative cost-effectiveness of MTF-provided care compared to civilian-provided care under varying assumptions, and document that information for decision makers to inform recommendations on future MTF restructuring decisions. Varying conditions could include different types of health care services, reducing the cost of military personnel salaries, and increasing estimated MTF wRVUs and civilian reimbursement rates. (Recommendation 4)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, establishes clear roles and responsibilities for executing and monitoring transitions for MTFs identified for restructuring. (Recommendation 5)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and described actions underway and planned to implement it. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, defines measurable objectives for MTF restructuring transitions, establishes thresholds and goals for each objective, and applies them to evaluate progress and challenges. For example, measurable objectives, thresholds, and goals, should include an evaluation of medical providers' clinical readiness, civilian health care provider adequacy, and the cost-effectiveness of MTF and purchased care. (Recommendation 6)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and described actions underway and planned to implement it. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Administrator of CMS should take steps to obtain quality information on the experiences of dual-eligible beneficiaries who have been default enrolled into D-SNPs, such as by obtaining information about the extent to which and reasons that beneficiaries disenroll from a D-SNP after being default enrolled. (Recommendation 1)

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.

Recommendation: The Under Secretary for Health should ensure that any action plan for achieving health equity includes key elements for successful implementation by consistently applying criteria identified in GAO's past work on effectively managing performance, including developing performance measures to assess progress and creating clear lines of accountability by designating specific offices or officials with responsibility for coordinating efforts to implement actions and committing resources necessary for achieving its goals and objectives. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

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

Recommendation: To ensure the availability of information on health care outcomes by race and ethnicity throughout the VA health care system, the Secretary of Veterans Affairs should conduct an assessment to determine the completeness and accuracy of race and ethnicity data captured in VA's electronic health record, and implement corrective actions as necessary to resolve any identified deficiencies. (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: Congress should consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements. (Matter for Consideration 1)

Agency: Congress
Status: Open

Comments: In October 2019, we suggested that Congress should consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements. As of June 2020, Congress has not implemented this suggestion.

Recommendation: The Administrator of CMS should incorporate the use of additional information, such as quality measures or other information that could identify potential quality of care issues, into its survey process for overseeing hospice providers. (Recommendation 1)

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

Comments: HHS concurred with this recommendation. In May 2020, HHS said CMS is evaluating ways in which the Hospice Consumer Assessment of Health Providers and Systems (CAHPS) survey data can be used to inform surveys of hospice providers. HHS also said CMS intends to incorporate use of the current Hospice Quality Reporting Program (HQRP) measurement data into the survey process to provide additional items that inform a surveyor's evaluation of a hospice provider. HHS noted that these changes would be incorporated into a more comprehensive update to the survey process to target providers and areas where risk of noncompliance is greatest. HHS projected the updated process would be implemented by the end of the first quarter of calendar year 2021. In order for us to close the recommendation, CMS has to implement an updated survey process that incorporates the use of additional information that could identify potential quality of care issues, such as that described above.

Recommendation: The Administrator of CMS should, to the extent feasible, maintain more complete information on both the total amount of funding allocated for quality measurement activities and the extent to which this funding supports each of its quality measurement strategic objectives. (Recommendation 1)

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.

Recommendation: The Administrator of CMS should develop and implement procedures to systematically assess the measures it is considering developing, using, or removing in terms of their impact on achieving CMS's strategic objectives and document its compliance with those procedures. (Recommendation 2)

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.

Recommendation: The Administrator of CMS should develop and use a set of performance indicators to evaluate the agency's progress towards achieving its quality measurement strategic objectives. (Recommendation 3)

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.

Recommendation: The Under Secretary of Health should require that all failures to meet quality standards are cited as deficiencies on SVH inspections. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA concurred with this recommendation and, as of July 2020, had taken some initial steps to address the recommendation such as modifying the SVH contractor's contract to stop the practice of using 'recommendations' for low-level deficiencies and beginning the process of revising a VA policy to address this practice.

Recommendation: The Under Secretary of Health should develop guidance for Veterans Affairs Medical Center staff conducting optional onsite CNH reviews. (Recommendation 3)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA concurred in principle with this recommendation and indicated in January 2020 that it had begun taking actions to address this recommendation such as developing a memo of clarification and planning the release of additional guidance for staff.

Recommendation: The Under Secretary of Health should provide information on the quality of all SVHs that is comparable to the information provided on the other nursing home settings on its Access to Care website. (Recommendation 4)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA concurred in principle and, as of July 2020, had begun taking some steps to address this recommendation such as exploring options for presenting SVH quality measure data.

Recommendation: The administrator of CMS should require that abuse and perpetrator type be submitted by state survey agencies in CMS's databases for deficiency, complaint, and facility-reported incident data, and that CMS systematically assess trends in these data. (Recommendation 1)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said CMS is developing the ability to review survey trends related to alleged perpetrator and alleged abuse types and aims to implement this recommendation by December 2020.

Recommendation: The administrator of CMS should develop and disseminate guidance—including a standardized form—to all state survey agencies on the information nursing homes and covered individuals should include on facility-reported incidents. (Recommendation 2)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said CMS will list the elements that all nursing homes should report to state agencies and aims to implement this recommendation by December 2020.

Recommendation: The administrator of CMS should require state survey agencies to immediately refer complaints and surveys to law enforcement (and, when applicable, to Medicaid Fraud Control Units (MFCU)) if they have a reasonable suspicion that a crime against a resident has occurred when the complaint is received. (Recommendation 3)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said CMS will require state survey agencies to immediately refer complaints upon receipt and surveys to law enforcement (and, when applicable, to Medicaid Fraud Control Units) if they have a reasonable suspicion that a crime against a resident has occurred and aims to implement this requirement by December 2020.

Recommendation: The administrator of CMS should conduct oversight of state survey agencies to ensure referrals of complaints, surveys, and substantiated incidents with reasonable suspicion of a crime are referred to law enforcement (and, when applicable, to MFCUs) in a timely fashion. (Recommendation 4)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said CMS will revise guidance to ensure state survey agencies will investigate and track incidents of abuse and neglect and report substantiated findings to local law enforcement. CMS aims to implement this recommendation by December 2020.

Recommendation: The administrator of CMS should develop guidance for state survey agencies clarifying that allegations verified by evidence should be substantiated and reported to law enforcement and state registries in cases where citing a federal deficiency may not be appropriate. (Recommendation 5)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said CMS will provide clarification to the state survey agencies regarding the definition of substantiated and when cases need to be referred to law enforcement. CMS aims to implement this recommendation by December 2020.

Recommendation: The administrator of CMS should provide guidance on what information should be contained in the referral of abuse allegations to law enforcement. (Recommendation 6)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said it will provide guidance to state agencies and nursing homes on identifying and reporting potential abuse and neglect of residents and will develop a list of standardized elements that should be included when reporting an abuse allegation to law enforcement. HHS aims to implement this recommendation by July 2020.

Recommendation: CMS should evaluate state survey agency processes in all states to ensure all state survey agencies are meeting federal requirements that state survey agencies are responsible for investigating complaints and facility-reported incidents alleging abuse in nursing homes, and that the results of those investigations are being shared with CMS. (Recommendation 1)

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

Comments: HHS concurred with this recommendation. As of November 2019, HHS officials have not informed us of actions taken to complete implementation of this recommendation. We will update the status of this recommendation when we receive additional information.

Recommendation: CMS should identify options for capturing information from Oregon's APS investigations of complaints and facility-reported incidents of abuse and incorporate this information into oversight of Oregon nursing homes. (Recommendation 2)

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

Comments: HHS concurred with this recommendation. As of November 2019, HHS officials have not informed us of actions taken to complete implementation of this recommendation. We will update the status of this recommendation when we receive additional information.

Recommendation: The Under Secretary for Health should ensure that facility officials who are responsible for credentialing, reviewing credentials, and hiring receive periodic mandatory training. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of March 2020, VA officials told us that they expect to have this recommendation implemented during calendar year 2020.

Recommendation: The Under Secretary for Health should develop policies and guidance regarding DEA registrations, including the circumstances in which Drug Enforcement Administration (DEA) waivers may be required, the process for requesting them, and a mechanism to ensure that facilities follow these policies. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of March 2020, this recommendation remains open. VA sent a letter to DEA asking for clarification about DEA employment waivers and received a response from DEA dated November 26, 2019. VA officials told us that they are considering the input from DEA and consulting with relevant stakeholders to determine next steps. To fully implement this recommendation, VA needs to provide evidence of actions taken to ensure that DEA requirements regarding DEA registrations and employment waivers are met. Such actions include developing policies regarding when a DEA employment waiver may be necessary and guidance about how to request such a waiver.

Recommendation: The Under Secretary for Health should identify and review providers whose DEA registrations were revoked or surrendered for cause and determine whether an employment waiver may be needed from DEA. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of March 2020, VA has reported important steps toward implementing this recommendation. Specifically, VA officials told us that they reviewed licensed independent practitioners to see if any that are currently employed at VA have a revoked or surrendered DEA registration. They identified at least one provider with a revoked or surrendered DEA registration. To fully implement this recommendation, VA needs to provide evidence that appropriate action was taken for this provider, such as obtaining a DEA waiver if necessary.

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: The Administrator of CMS should provide guidance and clarify requirements regarding the monitoring and reporting of deficiencies that states using home and community-based services (HCBS) waivers are required to report on their annual reports. (Recommendation 1)

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

Comments: CMS concurred with this recommendation and indicated the agency would provide guidance and clarify requirements regarding the monitoring and reporting of deficiencies in states' annual reports. According to CMS's fiscal year 2021 Budget Justification the agency expects to issue sub-regulatory guidance pertaining to health and welfare of Medicaid beneficiaries in residential facilities by the close of 2020.To fully implement this recommendation, the sub-regulatory guidance should clarify requirements for states' monitoring and reporting of deficiencies in HCBS annual reports. GAO will continue to monitor CMS actions in response to this recommendation.

Recommendation: The Administrator of CMS should establish standard Medicaid reporting requirements for all states to annually report key information on critical incidents, considering, at a minimum, the type of critical incidents involving Medicaid beneficiaries, and the type of residential facilities, including assisted living facilities, where critical incidents occurred. (Recommendation 2)

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

Comments: HHS neither agreed nor disagreed with this recommendation. According to CMS' fiscal year 2021 Budget Justification, the agency expects to issue sub-regulatory guidance pertaining to health and welfare of Medicaid beneficiaries in residential facilities by the close of 2020. To fully implement this recommendation, the sub-regulatory guidance should establish standard Medicaid reporting requirements for all states to report critical incidents annually. GAO will continue to monitor CMS actions in response to this recommendation.

Recommendation: The Administrator of CMS should ensure that all states submit annual reports for HCBS waivers on time as required. (Recommendation 3)

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

Comments: CMS concurred with this recommendation and stated that it will review and update its communications with states to reaffirm reporting requirements and ensure that all HCBS annual reports are submitted on time. According to CMS' fiscal year 2021 Budget Justification, the agency expects to issue sub-regulatory guidance pertaining to the health and welfare of Medicaid beneficiaries in residential facilities by the close of 2020. To fully implement this recommendation, the sub-regulatory guidance should ensure that all states submit annual reports on time. GAO will continue to monitor CMS actions in response to this recommendation.

Recommendation: The Undersecretary for Health should take additional steps to ensure that VA's website reports health care quality measures that cover a broad range of health care services, highlights key differences in the clinical quality of care, and presents this information in an easily accessible and understandable way (Recommendation 1).

Agency: Department of Veterans Affairs
Status: Open

Comments: As of January 2020, VA provided information that they had updated information on its website to include more quality measures, particularly as they relate to outpatient care. While VA has made progress in reporting on additional measures, we reviewed VA's website-specifically, their Access and Quality webpage which is the primary webpage for veterans to access information on quality-as of February 2020 and found that VA has still yet to report on a broad range of quality measures that would assist veterans in making health care decisions for inpatient care. For example, VA does not report any quality measures related to readmissions and mortality; length-of-stay; or efficiency. VA also continues to report only one timely and effective care measure for inpatient care. With regards to presentation of its quality measures, VA no longer links its Access and Quality webpage to the homepage of VA's website, making it more difficult to find. Additionally, for the new outpatient measures that VA has added to its website, VA has not presented these measures in an easily understandable way as there is little explanation of what they are measuring and how veterans can use these measures to make healthcare decisions. We will keep this recommendation open until VA has made further updates to its website.

Recommendation: The Undersecretary for Health should direct VA Central Office to conduct a systematic assessment of the completeness and accuracy of patient clinical information across VAMCs that is used to calculate the health care quality measures VA reports and address any deficiencies that affect the accuracy of these measures (Recommendation 2).

Agency: Department of Veterans Affairs
Status: Open

Comments: As of January 2020, VA has said they have focused on three main efforts as it relates to documenting information on VA quality of care, including: timeliness of access information (e.g., wait times) to health care within VA facilities; timeliness and accuracy of payments to community care providers; and accuracy of coding and documentation within VA and from community providers. In particular, VA has conducted several efforts to improve education and training on clinical documentation and coding, particularly for providers. VA has also said it has made efforts in requiring programs across regional networks aimed at improving clinical documentation and coding. While these efforts can help with improving documentation of care to veterans, it is unclear how VA Central Office has assessed whether these efforts have actually achieved its goals and improved the accuracy of its quality measures. As we stated in our report, VA Central Office has not conducted a systematic assessment of the completeness and accuracy of the clinical data recorded in VA patient medical records across all VAMCs. The results of such a systematic analysis could help identify the deficiencies, if any, in the recording of patient clinical information and what steps, if any, VA Central Office may need to take to address them. We will keep this recommendation open until VA provides information on a systematic assessment of clinical documentation.

Recommendation: To improve CMS's oversight of states' MLTSS programs, the Administrator of CMS should take steps to identify and obtain key information needed to oversee states' efforts to monitor beneficiary access to quality services, including, at a minimum, obtaining information specific to network adequacy, critical incidents, and appeals and grievances.

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

Comments: The Department of Health and Human Services (HHS) agreed with this recommendation. In December 2017, HHS communicated its intent to review regulations and enhance its capacity to measure, monitor, and improve care and quality across a number of domains, including MLTSS. As of February 2020, HHS stated that it is developing guidance related to reporting on key information needed to oversee beneficiary access to care. GAO will continue to monitor the department's actions and any steps taken to address this recommendation.

Recommendation: To ensure that the HVBP program accomplishes its goal to balance quality and efficiency and to ensure that it minimizes the payment of bonuses to hospitals with lower quality scores, the Administrator of CMS should revise the formula for the calculation of hospitals' total performance score or take other actions so that the efficiency score does not have a disproportionate effect on the total performance score.

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

Comments: HHS indicated that it would examine the formula used for calculating hospitals' total performance scores and consider revisions, which would be subject to notice and comment rulemaking. In September 2018, HHS indicated that it had been examining alternatives and considering revising the formula for the calculation of hospitals' total performance scores (TPS) consistent with relevant statutory guidance, and in a way to reduce the effect of the efficiency domain on the TPS. In the Fiscal Year 2019 Inpatient Prospective Payment System proposed rule, CMS proposed to remove the safety domain weighted at 25 percent of the TPS and, in connection, increase the weight of the clinical care domain from 25 percent to 50 percent, which was estimated to reduce the effect of the efficiency domain on the TPS. According to CMS, stakeholders were concerned about the safety domain removal and adverse impacts to rural and smaller hospitals due to increasing outcome measure relative weights. CMS indicated that it analyzed current data in the fall of 2018 and found a similar trend, where rural and small hospitals' payment would be adversely impacted from increasing outcome measure weights. CMS decided to keep measure weights to avoid adversely impacting rural and small hospitals. However, CMS did not take actions so that the efficiency score would not have a disproportionate effect on the total performance score and bonus payments to hospitals with lower quality scores. As of January 2020, the recommendation remains open.

Recommendation: To ensure that the HVBP program accomplishes its goal to balance quality and efficiency and to ensure that it minimizes the payment of bonuses to hospitals with lower quality scores, the Administrator of CMS should revise the practice of proportional redistribution used to correct for missing domain scores so that it no longer facilitates the awarding of bonuses to hospitals with lower quality scores.

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

Comments: HHS indicated that it would explore alternatives to the practice of proportional redistribution, and any changes to the distribution of weights for missing domains would be evaluated for potential negative impacts and would be subject to notice and comment rulemaking. In September 2018, HHS indicated that it was exploring alternatives and considering revising the practice of proportional redistribution used to correct for missing domain scores while also being mindful of any potential unintended consequences. In the Fiscal Year 2019 Inpatient Prospective Payment System proposed rule, CMS proposed to remove the safety domain and, in connection, to require scores for the remaining three domains in order to calculate the total performance score, but CMS did not finalize the weighting revision. CMS reported that stakeholders were concerned about the safety domain removal and any adverse impact to rural and smaller hospitals due to increasing outcome measure relative weights. CMS reported that it analyzed data and found that rural and small hospitals' payment would be adversely impacted from changing proportional redistribution to assign greater relative weight to outcomes. As a result, CMS decided to keep proportional redistribution. However, CMS's actions did not revise the practice of proportional redistribution, and, as a result, the practice may continue to facilitate the awarding of bonuses to hospitals with lower quality scores. As of January 2020, the recommendation remains open.

Recommendation: To accelerate efforts to develop a modern, credible, and effective performance management system the Assistant Secretary for HR&A should, with input from VHA stakeholders, ensure that meaningful distinctions are being made in employee performance ratings by (1) developing and implementing a standardized, comprehensive performance management training program for supervisors of Title 5, Title 38, and Title 38-Hybrid employees based on leading practices and ensuring procedures are in place to support effective performance conversations between supervisors and employees; (2) reviewing and revising Title 5 and Title 38 performance management policies consistent with leading practices (e.g., require definition of all performance levels); and (3) developing and implementing a process to standardize performance plan elements, standards, and metrics for common positions across VHA that are covered under VA's Title 5 performance management system.

Agency: Department of Veterans Affairs: Assistant Secretary for Human Resources and Administration
Status: Open
Priority recommendation

Comments: VA partially agreed with GAO's December 2016 recommendation. As of January 2020, VA has made progress toward addressing this recommendation. VA officials described a new pilot performance management system that is being used to develop an enterprise-wide performance management solution. VA officials also stated that they were developing policy revisions for performance management that are scheduled to be completed later this year. These actions, when fully implemented, should help VA make meaningful distinctions in performance and hold employees accountable.

Recommendation: To accelerate efforts to develop a modern, credible, and effective performance management system, the Assistant Secretary for HR&A should, with input from VHA stakeholders, develop a plan for how and when it intends to implement a modern information technology (IT) system to support employee performance management processes.

Agency: Department of Veterans Affairs: Assistant Secretary for Human Resources and Administration
Status: Open
Priority recommendation

Comments: The Department of Veterans Affairs (VA) partially agreed with GAO's December 2016 recommendation and as of January 2020 has made progress toward implementing the recommendation. For example, VA officials told GAO that they implemented a pilot project to develop a standard IT performance management system that started with about 12,000 employees and has expanded to about 67,00 employees. They told GAO that they are currently in the process of developing an enterprise-wide performance management IT solution. Activities such as finalizing a business case and analyzing alternatives are still in progress. GAO will continue to monitor VA's progress on this effort. Successful planning and implementation of a modern IT system should help VA capture reliable, timely, department-wide employee performance information and may also help VA realize cost savings by eliminating inefficient paper-based procedures.

Recommendation: To help improve the Five-Star System's ability to enable consumers to understand nursing home quality and make distinctions between high- and low- performing homes, the Administrator of CMS should add information to the Five-Star System that allows consumers to compare nursing homes nationally.

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

Comments: HHS did not concur with this recommendation. CMS officials told us in July 2019 that they do not plan to implement this recommendation. We maintain that adding national comparison information is important.

Recommendation: To improve the accessibility and reliability of SNF expenditure data, the Acting Administrator of CMS should take steps to improve the accessibility of SNF expenditure data, making it easier for public stakeholders to locate and use the data.

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

Comments: In September 2016, GAO recommended that CMS improve the accessibility and reliability of SNF expenditure data, thereby making it easier for public stakeholders to locate and use the data. The agency concurred with this recommendation in 2016 and stated that it would review the feasibility of increasing the accessibility of this data. However, in August 2017, HHS told GAO that it now believes that the cost of implementing this recommendation would outweigh its benefits. HHS confirmed in July 2019 that its position on this recommendation has not changed. GAO continues to hold that data on SNFs' relative expenditures should be readily accessible to the public to ensure transparency in SNF expenditures.

Recommendation: To improve the accessibility and reliability of SNF expenditure data, the Acting Administrator of CMS should take steps to ensure the accuracy and completeness of SNF expenditure data.

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

Comments: In September 2016, GAO recommended that CMS take steps to ensure the accuracy and completeness of SNF expenditure data. However, the agency did not concur with this recommendation. HHS reported in 2016 that the amount of time and resources to verify the accuracy and completeness of SNF expenditure data could be substantial, without assurance of benefit to the agency and the public. However, during the course of our work, GAO found that CMS uses this expenditure data to update overall SNF payment rates, in addition to more general purposes. GAO continues to believe that CMS should take steps to ensure reliable expenditure data are accurate and complete. As of July 2019, the agency continues to non-concur with this recommendation.

Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to include in the CMS Compare websites, to the extent feasible, estimated out-of-pocket costs for Medicare beneficiaries for common treatments that can be planned in advance.

Agency: Department of Health and Human Services
Status: Open

Comments: As of September 2019, 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: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to organize cost and quality information in the CMS Compare websites to facilitate consumer identification of the highest-performing providers, such as by listing providers in order based on their performance.

Agency: Department of Health and Human Services
Status: Open

Comments: As of September 2019, 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: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to include in the CMS Compare websites the capability for consumers to customize the information presented, to better focus on information relevant to them.

Agency: Department of Health and Human Services
Status: Open

Comments: As of September 2019, 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: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to develop specific procedures and performance metrics to ensure that CMS's efforts to promote the development and use of its own and others' transparency tools adequately address the needs of consumers.

Agency: Department of Health and Human Services
Status: Open

Comments: As of September 2019, 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: To help states identify and address quality-of-care concerns among individuals with developmental disabilities receiving Medicaid HCBS waiver services, the Administrator of CMS should encourage states to (1) include death as a critical incident and conduct mortality reviews if they do not already do so and (2) broaden their mortality review processes if they already include death as a critical incident and conduct mortality reviews.

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

Comments: As of August 2020, CMS had taken some steps to address this recommendation but additional actions are needed to fully implement it. In June 2018 CMS issued a Medicaid update to states explaining that CMS strongly encourages them to include unexpected deaths in their definition of reportable critical incidents. CMS also stated in the update that states should conduct a preliminary review of all beneficiary deaths and investigations should focus on those deaths determined to be unexpected. Further, CMS has shared with states best practices for state mortality reviews that include, for example, the use of an interdisciplinary review committee and taking actions to address identified quality of care problems. CMS also developed a webinar training (Incident Management 101) to help states improve their incident management systems for the Medicaid HCBS waiver. The webinar outlines the key elements of building a comprehensive incident management system (e.g., establishing a process for conducting investigations of incidents, tracking and trending incidents to help prevent and mitigate incidents from occurring) and reiterates CMS's expectation that states identify and address unexplained deaths on an ongoing basis in order to meet the waiver's health and welfare assurance. In late 2018, CMS planned to include in its revised waiver application questions to determine practices regarding states' review and evaluation of unexpected deaths. In September 2019, CMS officials notified us that it will provide an updated status report on this recommendation in November 2019. As of August 2020, CMS officials have not provided us information regarding its revised waiver application and technical guide. We will update the status of this recommendation when we receive this information.