Recommendation: To help address the uncertainty NIH faces, related to the potential impact of increasing indirect costs on its funding of future research, the Director of NIH should assess the impact of growth in indirect costs on its research mission, including, as necessary, planning for how to deal with potential future increases in indirect costs that could limit the amount of funding available for total research, including the direct costs of research projects.

Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health
Status: Open

Comments: As of July 7, 2015, NIH provided some information indicating that it had taken action to address our recommendation by tracking the size of indirect costs as a proportion of NIH's overall budget as part of the agency's annual budget planning process and risk assessment program. However, we determined that the actions did not fully address the recommendation because they focus on the agency's overall budget and do not assess the potential ongoing impact of indirect costs for universities on its mission. As of September 2018, NIH officials have not informed us of any additional actions taken to implement this recommendation. We will update the status of this recommendation when we receive additional information.

Recommendation: To ensure that nonmedical DOD research organizations coordinate with the Assistant Secretary of Defense for Health Affairs early in the research process to understand medical research requirements and avoid inefficiencies that may lead to duplicative work, the Secretary of Defense should direct the Under Secretary of Defense for Acquisition, Technology and Logistics to communicate to DOD's nonmedical research organizations the importance of coordination with the Joint Program Committee for Combat Casualty Care chair on combat casualty care issues, and require this coordination early in the research process when these organizations conduct research with implications for combat casualty care.

Agency: Department of Defense
Status: Open

Comments: DOD took several actions in 2014 to communicate to DOD's nonmedical research organizations the importance of coordination with the Joint Program Committee for Combat Casualty Care. Specifically, DOD chartered the Armed Services Biomedical Research Evaluation and Management Community of Interest to include both medical and non-medical researchers and to improve coordination, collaboration, and cooperation. DOD also appointed senior leaders to work in both this community of interest and in other DOD research communities of interest, to improve coordination. Furthermore, DOD conducted joint research meetings to share research data across the medical and non-medical communities. However, DOD had not indicated a requirement for this coordination to occur early in the research process, as included in GAO's recommendation. As of September 2019, DOD has not provided additional information or documentation to address this recommendation.

Recommendation: To ensure reliable measurement of veterans' wait times for medical appointments, the Secretary of VA should direct the Under Secretary for Health to take actions to improve the reliability of wait time measures either by clarifying the scheduling policy to better define the desired date, or by identifying clearer wait time measures that are not subject to interpretation and prone to scheduler error.

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA agreed with our recommendation. VA has taken actions intended to address the reliability of appointment wait times through improvements in appointment scheduling, including issuing a revised scheduling policy, providing and documenting scheduler training and improving oversight through scheduler audits. While the revised scheduling policy and subsequent guidance changed the terminology of wait time measures, it did not substantively clarify or define the desired date, one of the dates used for measuring appointment wait times. Therefore, we continue to believe that the desired date is still subject to interpretation and prone to scheduler error, which poses concerns for the reliability of wait times measured using the patient's desired date. Furthermore, in its internal audit report dated February 2019, VA reported it was unable to evaluate the accuracy and reliability of its wait-time data due to the lack of business rules for calculating them, indicating that additional efforts are needed to address this issue. In January 2020, VA reported to us that the internal audit did not test whether schedulers entered the patient's desired date into the scheduling system in compliance with VHA policy because of the lack of verifiable source documentation. Given our continued concerns about VA's ability to ensure the reliability of the wait-time data, we have requested additional information from VA about its wait time methodology and assessment of evidence underlying the audit findings.

Recommendation: To improve timely medical appointments and to address patient and staff complaints about telephone access,the Secretary of VA should direct the Under Secretary for Health to ensure that all VAMCs provide oversight of telephone access and implement best practices outlined in its telephone systems improvement guide.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and stated that VISN and VA Medical Center leadership would use best practices to develop and implement improved telephone service plans. As of March 2015, VA had developed a standardized telephone assessment tool and requested that facilities that care for 5,000 or more veterans complete the assessment and select actions for improvement based on its existing telephone systems improvement guide. Based on this request, VA received telephone assessment and improvement plans from 286 facilities that care for 5,000 or more veterans. VA is monitoring the facilities' telephone performance and is re-baselining call center infrastructure at each facility with a survey and new performance goals. In September 2015, VA issued an updated Telephone Access and Contact Management Improvement Guide. VA has also drafted an update to its directive on telephone access to outpatient care. As of July 2019, VA decided not to advance the draft policy for review and approval at this time, because of the significant uncertainty due to ongoing development of VA clinical contact centers and telehealth services. VA stated that it remains committed to developing sound policy related to virtual (telephone, video, and web-chat) access to clinical care.

Recommendation: To better balance the benefits of expedited rulemaking procedures with the benefits of public comments that are typically part of regular notice-and-comment rulemakings, and improve the quality and transparency of rulemaking records, the Director of OMB, in consultation with the Chairman of Administrative Conference of the United States (ACUS), should issue guidance to encourage agencies to respond to comments on final major rules, for which the agency has discretion, that are issued without a prior notice of proposed rulemaking.

Agency: Executive Office of the President: Office of Management and Budget
Status: Open

Comments: In a status update from OMB received on March 6, 2020, OMB stated that it agrees that agencies should respond to comments on final major rules, for which the agency has discretion, that are issued without a prior notice of proposed rulemaking. OMB says it will continue to prioritize this issue during review of regulations under EO 12866, and that it is currently considering whether additional guidance is appropriate and will consult with the staff of the Administrative Conference of the United States on this issue.

Recommendation: To improve transparency of and accountability for Medicaid non-DSH supplemental payments, Congress should consider requiring the Administrator of CMS to (1) improve state reporting of non-DSH supplemental payments, including requiring annual reporting of payments made to individual facilities and other information that the agency determines is necessary to oversee non-DSH supplemental payments; (2) clarify permissible methods for calculating non-DSH supplemental payments; and (3) require states to submit an annual independent certified audit verifying state compliance with permissible methods for calculating non-DSH supplemental payments.

Agency: Congress
Status: Open

Comments: No legislation enacted as of February 2020. However, CMS has taken some administrative actions, which are underway, to improve its oversight of non-DSH supplemental payments. In November 2019, CMS issued a proposed rule that the agency said would promote state accountability, improve federal oversight, and strengthen fiscal integrity of the Medicaid program. Among other things, the proposed rule would require states to report on non-DSH supplemental payments on a facility-specific basis, as well as specify data sources, data standards, and acceptable methods for demonstrating compliance for non-DSH supplemental payment calculations. GAO plans to continue to monitor congressional action and the status of the proposed rule, as well as review a final rule, if one is issued, to determine the extent to which they improve state reporting of non-DSH supplemental payments, clarify permissible methods for calculating non-DSH supplemental payments, and require audits to verify that states use permissible methods to calculate non-DSH supplemental payments.

Recommendation: To ensure that major steady state IT investments are being adequately analyzed, the Secretaries of Defense, Veterans Affairs, and the Treasury should direct appropriate officials to develop an OA policy, annually perform OAs on all investments, and ensure the assessments include all key factors.

Agency: Department of Veterans Affairs
Status: Open

Comments: For fiscal years 2013, 2014, and 2016, the Department of Veterans Affairs provided its operational analyses to GAO for its major information technology investments. These operational analyses addressed a majority of the key factors identified in Office of Management and Budget guidance. Nevertheless, in February 2019, the department was still in the process of finalizing its operational analysis policy and identified a target completion date of September 2019 for when the policy would be complete and ready for publication.