Recommendation: The Commissioner of the Social Security Administration should clarify policies and procedures to remind staff that a diagnosis of a substance use disorder is not necessary to conduct a Drug Addiction and Alcoholism evaluation. (Recommendation 1)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation. The agency stated that it had revised related policies in February 2020, and had planned to issue guidance and video-on-demand training to further clarify policies and procedures in this area. However, SSA said its efforts to maintain mission critical activities amid the COVID-19 pandemic have delayed further implementation of this recommendation and a specific implementation date could not be provided at this time.

Recommendation: The Commissioner of the Social Security Administration should ensure that staff document their rationale for decisions involving the Drug Addiction and Alcoholism evaluation process. (Recommendation 2)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation. The agency said it had planned to issue guidance reinforcing its policy on properly documenting decisions involving the Drug Addiction and Alcoholism evaluation process. However, SSA said its efforts to maintain mission critical activities amid the COVID-19 pandemic have delayed implementation of this recommendation and a specific implementation date could not be provided at this time.

Recommendation: The Secretary of Labor, in conducting any assessment of its staff training designed to improve clarity of communication with claimants, should ensure that the assessment considers claimants' challenges with understanding DOL's written communications on the evidence needed to successfully reopen or otherwise support a claim.

Agency: Department of Labor
Status: Open

Comments: DOL neither agreed nor disagreed with this recommendation. However, DOL acknowledged that it plans to focus its staff training efforts on a variety of needed training topics, including improving the quality of written communications. DOL further noted that its recently hired training analyst will be responsible for, among other things, designing assessment measures to gauge the quality of training and the effect it has improving the overall quality of claim outcomes. We encourage DOL to continue designing its assessment so that it considers claimants' challenges in understanding the evidence needed. As of July 2019, DOL said it will soon contract with a training vendor to help update training materials and expects training to be rolled out in fiscal year 2020. In addition, DOL said it has conducted hands-on staff training that includes providing claimants with a clear understanding as to why a claim is accepted or denied. We will consider closing this recommendation pending implementation of the updated training and efforts to assess it.

Recommendation: The Commissioner of FDA should develop a timeline for updating the risk assessment on arsenic in rice. (Recommendation 1)

Agency: Department of Health and Human Services: Food and Drug Administration
Status: Open

Comments: As of August 2020, FDA stated that it will update the risk assessment when more scientific evidence becomes available. In the meantime, FDA noted that it will continue to monitor research in this area, including ongoing work by the National Academies of Sciences (NAS) Board on Environmental Studies and Toxicology, which is currently reviewing EPA's work on inorganic arsenic, specifically on EPA's IRIS Toxicological Assessments of Inorganic Arsenic. GAO will assess whether FDA has taken action responsive to the recommendation when additional information becomes available.

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 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.

Recommendation: To further align Medicare beneficiary use of preventive services with Task Force recommendations, Congress may wish to consider requiring beneficiaries who receive services with a grade of 'D" to share the cost, notwithstanding that cost sharing may not be required for other beneficiaries receiving the same services.

Agency: Congress
Status: Open

Comments: As of June 2020, Congress has not yet taken action to require beneficiaries who receive services with a Task Force grade of "D" to share the cost.

Recommendation: The Administrator of CMS should take steps to better align Medicare beneficiary use of preventive services with Task Force recommendations, including providing coverage of services with an 'A" or 'B" grade for the recommended population and at the recommended frequency, as she determines is appropriate considering cost-effectiveness and other criteria.

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

Comments: CMS has noted that it extended Medicare coverage for several additional preventive services, and that it continues to review the Task Force's recommendations. Specifically, the agency noted that it closely monitors Task Force updates and attends relevant meetings so that alignment with the Medicare population can be considered. However, until CMS implements a systematic process within routine coverage determination steps to regularly consider Task Force guidelines, beneficiaries remain at risk for unnecessary coverage limitations. As of October 2019, CMS officials have not implemented this recommendation and GAO considers it to be open. We will update the status of this recommendation when we receive additional information.