GAO

GAO-20-616, Substance Use Disorder: Medicaid Coverage of Peer Support Services for Adults, August 06, 2020

Substance use disorders (SUD)—the recurrent use of alcohol or illicit drugs causing significant impairment—affected about 19.3 million adults in the United States in 2018, according to the Substance Abuse and Mental Health Services Administration. State Medicaid programs have the option to cover services offered by peer providers—individuals who use their own lived experience recovering from SUD to support others in recovery. GAO's review of Medicaid and CHIP Payment and Access Commission data found that, in 2018, 37 states covered peer support services for adults with SUDs in their Medicaid programs. Medicaid Coverage of Peer Support Services for Adults with Substance Use Disorders, 2018 Officials from the three states GAO reviewed—Colorado, Missouri, and Oregon—reported that their Medicaid programs offered peer support services as a complement, rather than as an alternative, to clinical treatment for SUD. Missouri officials said that peer providers did not maintain separate caseloads and were part of treatment teams, working in conjunction with doctors and other clinical staff. Similarly, officials in Colorado and Oregon said peer support services were only offered as part of a treatment plan. State officials reported that peer support services could be offered as an alternative to clinical treatment outside of Medicaid using state or grant funding. SUD treatment can help individuals reduce or stop substance use and improve their quality of life. In 2007, the Centers for Medicare & Medicaid Services recognized that peer providers could be an important component of effective SUD treatment, and provided guidance to states on how to cover peer support services in their Medicaid programs. However, states have flexibility in how they design and implement their Medicaid programs, and coverage for peer support services is an optional benefit. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act included a provision for GAO to report on peer support services under Medicaid. This report describes, among other objectives, the extent to which state Medicaid programs covered peer support services for adult beneficiaries with SUDs nationwide, and how selected state Medicaid programs offered peer support services for adult beneficiaries with SUDs. GAO obtained state-by-state data from the Medicaid and CHIP Payment and Access Commission on 2018 Medicaid coverage of peer support services. GAO also reviewed information and interviewed officials from a nongeneralizable sample of three states, which GAO selected for a number of reasons, including to obtain variation in delivery systems used. The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate. For more information, contact Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov.

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GAO-20-579, Next Generation Combat Vehicles: As Army Prioritizes Rapid Development, More Attention Needed to Provide Insight on Cost Estimates and Systems Engineering Risks, August 06, 2020

The four efforts within the Next Generation Combat Vehicles (NGCV) portfolio all prioritize rapid development, while using different acquisition approaches and contracting strategies. Some of the efforts use the new middle-tier acquisition approach, which enables rapid development by exempting programs from many existing DOD acquisition processes and policies. Similarly, the efforts use contracting strategies that include both traditional contract types as well as more flexible approaches to enable rapid development of technology and designs. Vehicles of the Next Generation Combat Vehicles Portfolio The two programs within the portfolio that recently initiated acquisitions—Mobile Protected Firepower and Optionally Manned Fighting Vehicle—have taken some steps to mitigate risks in cost and technology consistent with GAO's leading practices. The Army's use of the middle-tier approach for these efforts may facilitate rapid development, but the programs could benefit from additional application of GAO's leading practices. For example, the programs identified some risks in their cost estimates, but because each presented a single estimate of the total cost—referred to as a point estimate—these estimates do not fully reflect how uncertainty could affect costs. Similarly, the programs took some steps to mitigate technical risk by limiting development to 6 years or less and incrementally introducing new technologies, steps consistent with GAO's leading practices. However, by delaying key systems engineering reviews, the programs took some steps not consistent with leading practices, which could increase technical risk. While trade-offs may be necessary to facilitate rapid development, more consistent application of GAO's leading practices for providing cost estimates that reflect uncertainty and conducting timely systems engineering reviews could improve Army's ability to provide insight to decision makers and deliver capability to the warfighter on time and at or near expected costs. The Army has taken actions to enhance communication, both within the Army and with Department of Defense stakeholders, to mitigate risks. Within the Army, these actions included implementing a cross-functional team structure to collaboratively develop program requirements with input from acquisition, contracting, and technology development staff. Program officials also coordinated with other Army and Department of Defense stakeholders responsible for cost and test assessment, even where not required by policy, to mitigate risk. The Army views the NGCV portfolio as one of its most critical and urgent modernization priorities, as many current Army ground combat vehicles were developed in the 1980s or earlier. Past efforts to replace some of these systems failed at a cost of roughly $23 billion. In November 2017, the Army began new efforts to modernize this portfolio. GAO was asked to review the Army's plans for modernizing its fleet of ground combat vehicles. This report examines (1) the acquisition approaches and contracting strategies the Army is considering for the NGCV portfolio, (2) the extent to which the Army's efforts to balance schedule, cost, and technology are reducing acquisition risks for that portfolio, and (3) how the Army is communicating internally and externally to reduce acquisition risks. GAO reviewed the acquisition and contracting plans for each of the vehicles in the portfolio to determine their approaches; assessed schedule, cost, and technology information—where available—against GAO's leading practice guides on these issues as well as other leading practices for acquisition; and interviewed Army and DOD officials. GAO is making three recommendations, including that the Army follow leading practices on cost estimation and systems engineering to mitigate program risk. In its response, the Army concurred with these recommendations and plans to take action to address them. For more information, contact Jon Ludwigson at (202) 512-4841 or ludwigsonj@gao.gov.

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GAO-20-619, Natural Gas Exports: Updated Guidance and Regulations Could Improve Facility Permitting Processes, August 06, 2020

Federal agencies have incorporated most but not all key collaboration practices in the permitting processes for export facilities for liquefied natural gas (LNG). GAO has identified seven key practices that can help sustain collaboration among federal agencies, including reviewing and updating written guidance and agreements. The Maritime Administration (MARAD) and the U.S. Coast Guard (Coast Guard), which jointly lead the permitting process for LNG export facilities in federal waters, have incorporated all seven key practices. The Federal Energy Regulatory Commission (FERC), which leads the permitting process for LNG export facilities located on land or in state waters (facilities in both places are referred to as onshore facilities), has incorporated six of the key practices. However, FERC does not regularly review and update its interagency agreements, which outline agencies' roles and responsibilities in the onshore permitting process, because it does not have a process to do so. Establishing a process to regularly review and update FERC's agreements with other agencies would help FERC ensure that, in the near term, other agencies clearly understand and consistently implement the permitting process and, for the longer term, the agreements address policy changes that may affect the process. FERC's, the Pipeline and Hazardous Materials Safety Administration's (PHMSA), and the Coast Guard's regulations for permitting LNG export facilities do not incorporate all current technical standards. For example, FERC's regulations cite an outdated 1984 earthquake standard, PHMSA's regulations cite outdated fire safety standards from 2001, and the Coast Guard's regulations cite an outdated 1994 standard for fire extinguishers. Guidance from the Office of Management and Budget states that agencies should conduct a standards-specific review of regulations that cite technical standards every 3 to 5 years and update the regulations with updated standards, if necessary. However, FERC, PHMSA, and the Coast Guard have not recently conducted such a review and FERC and PHMSA do not have processes in place to regularly do so. The Coast Guard has a process for conducting such reviews but it does not specify how frequently the reviews should occur. Without processes to conduct a standards-specific review of regulations every 3 to 5 years, the agencies cannot be assured that the regulations remain effective at ensuring safety. Onshore Export Facilities for Liquefied Natural Gas (LNG) As U.S. natural gas production has increased, exports of natural gas have increased as well, and in 2017, the nation became a net exporter of natural gas. In 2019, about 39 percent of natural gas exports were transported by ship as LNG, and exports of LNG are expected to grow. FERC, MARAD, and the Coast Guard issue permits required for companies to construct or operate an LNG export facility. The Coast Guard, along with PHMSA, also has issued regulations on safety and technology requirements for these facilities. These regulations incorporate technical standards that are developed and updated by standards-developing organizations. GAO was asked to review how federal agencies manage the permitting processes. This report examines, among other things, the extent to which (1) federal agencies collaborate in the permitting processes for LNG export facilities and (2) regulations for such facilities incorporate current technical standards. GAO analyzed agency documents and interviewed agency officials, LNG export company representatives, and other stakeholders. GAO is making nine recommendations, including that FERC establish a process to regularly review and update its agreements with other agencies for the onshore facility permitting process and that FERC, PHMSA, and the Coast Guard establish processes to conduct standards-specific reviews of regulations every 3 to 5 years. The agencies agreed with GAO's recommendations and identified actions to address them. For more information, contact Frank Rusco at (202) 512-3841 or ruscof@gao.gov.

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GAO-20-600, Native American Youth: Agencies Incorporated Almost All Leading Practices When Assessing Grant Programs That Could Prevent or Address Delinquency, August 06, 2020

The Departments of Justice (DOJ), Health and Human Services (HHS), the Interior (Interior), and Education (Education) administered at least 38 grant programs from fiscal years 2015 through 2018 that could have helped prevent or address delinquency among Native American youth. These agencies made about $1.9 billion in awards to grantees through these programs during this period. These agencies incorporated almost all of the leading practices GAO identified for performance measurement or program evaluation when assessing the performance of selected grant programs. For example, HHS's Administration for Children and Families (ACF) incorporated 13 of the 14 leading practices for performance measurement but did not fully assess grantee data reliability for one of its programs. By developing a process to assess the reliability of grantee data contained in the annual performance reports that tribal recipients submit, ACF could obtain further assurance that it has an accurate representation of grantee performance. GAO also found that Interior's Bureau of Indian Education (BIE) did not conduct formal data reliability checks on performance data that grantees report and did not always collect performance reports from grantees in a timely manner for one of its programs. By developing a process to assess the reliability of a sample of grantee performance data and taking steps to alert grantees when they are late in submitting performance reports, BIE could better ensure that grantees are complying with the terms and conditions of the grant program and better understand how the program and its grantees are performing. Officials in all 12 interviews with tribes or tribal consortia GAO interviewed cited risk factors that contribute to juvenile delinquency in their communities. Number of Interviews in Which Tribal Officials Cited Risk Factors Contributing to Juvenile Delinquency Note: The figure includes the most common risk factors tribal officials cited for juvenile delinquency. While tribal officials cited restrictions placed on federal grant funding, difficulty communicating with program staff, and challenges hiring and retaining staff as barriers to implementing federal programs, they also identified promising practices, such as executing culturally relevant programs, for preventing or addressing juvenile delinquency. Federal and other studies have noted that exposure to violence and substance abuse make Native American youth susceptible to becoming involved with the justice system. GAO was asked to examine federal and tribal efforts to address juvenile delinquency and the barriers tribes face in doing so. This report examines (1) federal financial assistance targeting tribes that could prevent or address juvenile delinquency; (2) the extent to which federal agencies assess the performance of selected grant programs and incorporate leading practices; and (3) the juvenile delinquency challenges tribes report facing. GAO identified relevant grant programs during fiscal years 2015 through 2018—the most recent data available when GAO began the review. GAO analyzed documents and interviewed agency officials to determine how they assessed grant program performance and conducted interviews with 10 tribes and two tribal consortia to discuss challenges with delinquency. GAO is making three recommendations, including that relevant HHS and Interior offices develop a process to assess the reliability of tribal grantee performance information and that an Interior office take steps to alert grantees that are late in submitting progress reports. Interior concurred with the two recommendations. HHS disagreed with GAO's recommendation. GAO clarified the recommendation to HHS and continues to believe it is warranted. For more information, contact Gretta L. Goodwin, (202) 512-8777, or GoodwinG@gao.gov.

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GAO-20-566, Federal Financial Management: Substantial Progress Made since Enactment of the 1990 CFO Act; Refinements Would Yield Added Benefits, August 06, 2020

Since enactment of the Chief Financial Officers Act of 1990 (CFO Act), the federal government has significantly improved its financial management, though challenges remain. Progress Made in Federal Financial Management since the CFO Act Leadership Centralized leadership structures were established—Deputy Director for Management and Controller positions and chief financial officers (CFO). Office of Management and Budget (OMB) prepared government-wide plans, issued guidance, and directed financial management activities. Department of the Treasury (Treasury) issued financial reporting guidance and a 10-year vision for federal financial management. CFO Council undertook initiatives to address government-wide financial management issues. Inspectors general recommended improvements in government operations and prevented and detected fraud, waste, and abuse. Financial reporting Agencies’ audited financial statements improved accountability (see figure). Since fiscal year 1997, Treasury, in coordination with OMB, annually prepared consolidated financial statements for the U.S. government. Federal Accounting Standards Advisory Board issued 58 standards. Number of Unmodified (“Clean”) Audit Opinions for Chief Financial Officers Act of 1990 Agencies for Fiscal Years 1996 through 2019 Internal control CFO Act agencies significantly improved their internal controls, increasing the reliability of their financial information. Treasury and OMB made significant progress in improving controls related to the consolidated financial statements of the U.S. government. Annual audits identified the significance of improper payments and information security weaknesses. Financial management systems CFO Act agencies took steps to improve financial management systems and use government-wide providers for certain agency functions (e.g., payroll). Financial management workforce Office of Personnel Management periodically updated key standards. Challenges That Remain in Federal Financial Management Leadership CFOs would benefit from standardized financial management responsibilities to provide them with the necessary authorities to achieve the full potential of the CFO Act. Deputy CFO positions would be strengthened by defined financial management responsibilities consistent with the breadth of those of the agency CFO. With frequent CFO turnover and a potentially lengthy vacancy period, long-term planning and leadership continuity can be affected. Government-wide financial management plans, prepared every 4 years, would help to address long-standing, costly, and challenging concerns in a strategic, comprehensive, and cost-effective manner. Annual government-wide plans, required by the CFO Act, were last prepared by OMB for fiscal year 2009. Financial reporting Improving the linking of agency performance and cost information would help policymakers and managers make fully informed decisions. Agencies currently have limited financial management performance-based metrics to help them assess the quality of their financial management. Agencies may not have key financial management information needed for decision-making, such as for grants management. Without identifying and, if necessary, developing this information, the government cannot adequately ensure accountability or manage for results. Internal control Agencies may not have reasonable assurance that key financial management information is reliable. Without separately assessing and reporting on the effectiveness of internal controls over financial reporting and other key financial management information and independent audit testing, management lacks reasonable assurance of the reliability of such information. Opportunities exist to address government-wide improper payments, which were estimated at about $175 billion for fiscal year 2019. Material weaknesses continue to prevent an audit opinion on the U.S. government’s consolidated financial statements. Financial management systems Opportunities exist for improving financial management systems to reduce frequent failures or cost overruns and lengthy delays in deployment, and increase compliance with systems requirements. Some agencies rely on legacy systems that use outdated languages, are costly to maintain, and may not report reliable information. The widespread adoption of shared services—government-wide providers handling certain agency functions—faces challenges, thereby limiting cost savings. Financial management workforce Comprehensive planning could help agencies build a federal financial management workforce that can adapt to modern needs and close skills gaps. Prior to enactment of the CFO Act, federal agencies lost billions of dollars through fraud, waste, abuse, or mismanagement. The CFO Act was enacted, in part, to address these problems—calling for comprehensive federal financial management reform. Among other things, the act established CFO positions, provided for long-range planning, and began the process of auditing federal agency financial statements. The act also called for integrating accounting and financial management systems, and systematic performance measurement and cost information. GAO was asked to review federal financial management since the CFO Act. This report discusses (1) progress the federal government has made in achieving the purposes of the CFO Act and improving federal financial management and (2) remaining challenges for the federal government in achieving effective government-wide financial management. GAO reviewed relevant laws, guidance, and reports; conducted interviews of current and former federal financial management officials; held a discussion group with former CFOs and a panel discussion with experts in federal financial management; and conducted surveys of CFOs, inspectors general, and independent public accountants. GAO is identifying eight matters for congressional consideration, including that Congress consider legislation to require CFOs at the CFO Act agencies to have the responsibilities necessary to effectively carry out federal financial management activities; deputy CFOs at the CFO Act agencies to have defined responsibilities consistent with the breadth of those of the agency CFO; preparation of government-wide and agency-level 4-year financial management plans, including actions to improve financial management systems, strengthen the federal financial management workforce, and better link performance and cost information for decision-making, as well as an annual financial management status report; preparation of comprehensive financial management performance-based metrics and reporting of executive agencies’ performance against the metrics; and identification and, if necessary, development of key financial management information needed for effective financial management and decision-making as well as annual assessments and reporting by management on the effectiveness of internal control over the information and auditor testing and reporting on internal control over the information. Treasury and OPM provided technical comments on the draft report. In its oral comments, OMB stated that it appreciated the incorporation of its views into the draft report and reemphasized its concerns relating to two matters for congressional consideration—a government-wide 4-year financial management plan and an annual status report and agencies assessing and reporting on the effectiveness of internal controls over key financial management information. GAO continues to believe that these measures would improve federal financial management. For more information, contact Dawn B. Simpson at (202) 512-3406 or simpsondb@gao.gov or Robert F. Dacey at (202) 512-3406 or daceyr@gao.gov.

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GAO-20-532, Defense Workforce: DOD Needs to Assess Its Use of Term and Temporary Appointments, August 06, 2020

The Department of Defense (DOD) uses term and temporary appointments to hire personnel to non-permanent positions that have uncertain funding or workload. During fiscal years 2016 through 2019, DOD increased term personnel by 40 percent and decreased temporary personnel by 3 percent, according to GAO analysis. Number of DOD Term and Temporary Personnel, Fiscal Years 2016—2019 According to GAO analysis of DOD data, during fiscal years 2016 through 2019: Approximately 35 percent of DOD term and temporary personnel were converted to permanent civilian positions within the federal government. The Army employed 72 percent of DOD's term and temporary personnel. Two Army organizations—Army Tank-automotive and Armaments Command and the U.S. Army Corps of Engineers—employed 32 percent of DOD's term and temporary personnel. This large use was due to increases in ground combat equipment returning from overseas operations needing to be repaired at the Army depots, and U.S. Army Corps of Engineers work to support disaster relief, according to DOD officials. DOD modified the procedures for making term appointments in June 2017 and August 2018, and temporary appointments in June 2017. These modifications extended the duration limit for term appointments from 4 years to 8 years, with further extensions considered on a case-by-case basis; allowed an option for certain term personnel to be non-competitively converted to permanent positions; and extended the duration limit for temporary appointments from 2 years to 3 years. However, DOD did not assess employee perceptions of the 2017 modifications and report the results of the assessment to Congress and GAO, as required by statute. In October 2019, DOD officials told GAO that they mistakenly believed Congress had waived this requirement, and that they plan to complete the assessment and report to Congress and GAO. In commenting on a draft of this report, DOD established a timeframe of May 2021 for completing a survey to assess employee perceptions. This is a positive step, but it will be important for DOD to provide the results of the assessment to Congress and GAO. DOD employs term and temporary personnel as a part of its overall civilian workforce. Recently, DOD extended the maximum duration of term appointments to 8 years with further extensions considered on a case-by-case basis, and temporary appointments to 3 years. House Report 116-120 included a provision for GAO to review DOD's use of term and temporary hiring authorities. GAO's report (1) identifies changes in the number of DOD term and temporary personnel from fiscal years 2016 through 2019, and (2) assesses the extent to which DOD modified term and temporary appointments and completed and submitted a statutorily required report assessing those modifications. GAO analyzed DOD personnel data from fiscal years 2016 through 2019 to identify any changes, DOD memoranda modifying term and temporary appointments, and relevant statutes; and interviewed DOD and Office of Personnel Management officials. GAO recommends that DOD report the results of the assessment of employee perceptions of modifications to term and temporary appointments to Congress and GAO. DOD concurred with the recommendation. For more information, contact Elizabeth Field at (202) 512-2775 or fielde1@gao.gov.

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GAO-20-488, Climate Change: A Climate Migration Pilot Program Could Enhance the Nation's Resilience and Reduce Federal Fiscal Exposure, July 06, 2020

GAO identified few communities in the United States that have considered climate migration as a resilience strategy, and two—Newtok, Alaska, and Isle de Jean Charles, Louisiana—that moved forward with relocation. Newtok, for example, faced imminent danger from shoreline erosion due to thawing permafrost and storm surge (see figure). Literature and experts suggest that many more communities will need to consider relocating in coming decades. Shoreline Erosion at Newtok, Alaska, from July 2007 to October 2019. Federal programs provide limited support to climate migration efforts because they are designed to address other priorities, according to literature GAO reviewed and interviews with stakeholders and federal officials. Federal programs generally are not designed to address the scale and complexity of community relocation and generally fund acquisition of properties at high risk of damage from disasters in response to a specific event such as a hurricane. Unclear federal leadership is the key challenge to climate migration as a resilience strategy. Because no federal agency has the authority to lead federal assistance for climate migration, support for climate migration efforts has been provided on an ad hoc basis. For example, it has taken over 30 years to begin relocating Newtok and more than 20 years for Isle de Jean Charles, in part because no federal entity has the authority to coordinate assistance, according to stakeholders in Alaska and Louisiana. These and other communities will rely on post-disaster assistance if no action is taken beforehand—this increases federal fiscal exposure. Risk management best practices and GAO's 2019 Disaster Resilience Framework suggest that federal agencies should manage such risks before a disaster hits. A well-designed climate migration pilot program that is based on project management best practices could improve federal institutional capability. For example, the interagency National Mitigation Investment Strategy—the national strategy to improve resilience to disasters—recommends that federal agencies use pilot programs to demonstrate the value of resilience projects. As GAO reported in October 2019, a strategic and iterative risk-informed approach for identifying and prioritizing climate resilience projects could help target federal resources to the nation's most significant climate risks. A climate migration pilot program could be a key part of this approach, enhancing the nation's climate resilience and reducing federal fiscal exposure. According to the 13-agency United States Global Change Research Program, relocation due to climate change will be unavoidable in some coastal areas in all but the very lowest sea level rise projections. One way to reduce the risks to these communities is to improve their climate resilience by planning and preparing for potential hazards related to climate change such as sea level rise. Climate migration—the preemptive movement of people and property away from areas experiencing severe impacts—is one way to improve climate resilience. GAO was asked to review federal support for climate migration. This report examines (1) the use of climate migration as a resilience strategy; (2) federal support for climate migration; and (3) key challenges to climate migration and how the federal government can address them. GAO conducted a literature review of over 52 sources and interviewed 12 climate resilience experts. In addition, GAO selected and interviewed 46 stakeholders in four communities that have considered relocation: Newtok, Alaska; Santa Rosa, California; Isle de Jean Charles, Louisiana; and Smith Island, Maryland. Congress should consider establishing a pilot program with clear federal leadership to identify and provide assistance to communities that express affirmative interest in relocation as a resilience strategy. The Departments of Homeland Security and Housing and Urban Development provided technical comments that GAO incorporated as appropriate. For more information, contact Alfredo Gómez at (202) 512-3841 or gomezj@gao.gov.

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GAO-20-617, Opioid Use Disorder: Treatment with Injectable and Implantable Buprenorphine, August 04, 2020

Of the medications used to treat opioid use disorder (OUD), only buprenorphine is both a controlled substance and available as an injection or implant. Buprenorphine is used to treat patients with OUD because it reduces or eliminates opioid withdrawal symptoms and blunts the euphoria or dangerous side effects of other opioids, such as heroin. When used to treat OUD, buprenorphine, in any form, is subject to additional laws and regulations that are overseen by the Drug Enforcement Administration (DEA), within the Department of Justice (DOJ) and the Substance Abuse and Mental Health Services Administration (SAMHSA), within the Department of Health and Human Services (HHS). To ensure patient safety when injectable and implantable buprenorphine is used, the Food and Drug Administration (FDA), within HHS has also required drug companies to establish risk evaluation and mitigation strategies to help ensure the benefits of these medications outweigh their risks. Providers and pharmacies must follow a number of specific steps based on federal requirements when providing treatment with injectable and implantable buprenorphine. Providers are responsible for prescribing, storing, and administering injectable and implantable buprenorphine, while pharmacies are responsible for dispensing these medications (see figure). Representatives GAO interviewed from provider groups and pharmacies said they did not find the steps involved in treating patients to be difficult overall. However, they stated that careful and timely coordination with each other and patients is needed at key steps of the process to ensure that the patient receives treatment. Representatives from provider groups and pharmacies reported that the risk of diversion of injectable and implantable buprenorphine is low. For example, all of the provider groups GAO spoke with said that diversion of injectable or implantable buprenorphine is unlikely, and representatives from three of the six provider groups said that the design of these formulations reduces opportunities for diversion due to how they are administered. Process for Treating Opioid Use Disorder with Injectable and Implantable Buprenorphine The use of injectable and implantable buprenorphine to treat OUD is relatively low compared to oral forms of buprenorphine. HHS has reported that about 7,250 prescriptions were issued for injectable and implantable buprenorphine in fiscal year 2019, compared to over 700,000 patients who received buprenorphine prescriptions for oral formulations to treat OUD or pain in that year. In 2018, SAMHSA estimated that about one-quarter of the estimated 2 million people with OUD had received some form of substance use treatment in the prior year. One form of treatment—medication-assisted treatment (MAT)— combines behavioral therapy with the use of certain medications. HHS has identified expanding access to treatment for OUD as an important strategy for reducing opioid morbidity and mortality, which includes increasing the number of injectable and implantable buprenorphine prescriptions. Congress included a provision in the SUPPORT Act for GAO to review access to and the potential for the diversion of controlled substances administered by injection or implantation. This report focuses on injectable and implantable controlled substances that can be used to treat OUD and specifically, describes the process for treating OUD with injectable and implantable buprenorphine and what is known about their use. GAO reviewed laws, regulations, and documentation from DEA, FDA, and SAMHSA governing the process of providing treatment with buprenorphine and interviewed officials from those agencies. GAO also interviewed representatives from stakeholder groups representing MAT providers; drug companies that manufacture injectable or implantable buprenorphine; and pharmacies that dispense these medications. HHS and DOJ reviewed a draft of this report, and GAO incorporated their technical comments, as appropriate. For more information, contact James Cosgrove at (202) 512-7114 or cosgrovej@gao.gov.

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GAO-20-691T, Information Technology: Federal Agencies and OMB Need to Continue to Improve Management and Cybersecurity, August 03, 2020

Federal agencies and the Office of Management and Budget (OMB) have taken steps to improve the management of information technology (IT) acquisitions and operations and ensure the nation's cybersecurity through a series of initiatives. As of July 2020, federal agencies had fully implemented 64 percent of the 1,376 IT management-related recommendations that GAO has made to them since fiscal year 2010. Likewise, agencies had implemented 79 percent of the 3,409 security-related recommendations that GAO has made since fiscal year 2010. However, significant actions remain to be completed to build on this progress. Chief Information Officer (CIO) responsibilities. Laws such as the Federal Information Technology Acquisition Reform Act (FITARA) and related guidance assign 35 key responsibilities to agency CIOs to help address longstanding IT management challenges. In August 2018, GAO reported that none of the 24 selected agencies had established policies that fully addressed the role of their CIO. GAO recommended that OMB and the 24 agencies take actions to improve the effectiveness of CIOs' implementation of their responsibilities. Although most agencies agreed or did not comment, only four of the 27 recommendations have been implemented. CIO IT acquisition review. According to FITARA, covered agencies' CIOs are required to review and approve IT contracts. Nevertheless, in January 2018, GAO reported that most of the CIOs at 22 covered agencies were not adequately involved in reviewing billions of dollars of IT acquisitions. Since then, agencies implemented 29 out of 39 recommendations made to improve CIO oversight for these acquisitions. Implementing the remaining 10 could increase CIOs' authority and improve the management of IT contracts. Consolidating data centers. OMB launched an initiative in 2010 to reduce data centers. According to the 24 covered agencies, this initiative has resulted in approximately $4.7 billion in cost savings from fiscal years 2012 through 2019. Even so, additional work remains. As of July 2020, OMB and agencies implemented 133 of the 204 recommendations made to improve the reporting of related cost savings and to achieve optimization targets. Implementing the remaining recommendations could yield additional cost savings. Managing software licenses. Effective management of software licenses can help avoid purchasing too many licenses that result in unused software. In May 2014, GAO reported that better management of licenses was needed to achieve savings and made 135 recommendations to improve such management. Agencies have implemented 123 of the 135 recommendations. Implementing the remaining 12 could reduce spending and duplication. Ensuring the nation's cybersecurity. GAO continues to designate information security as a government-wide high-risk area due to increasing cyber-based threats and the persistent nature of security vulnerabilities. Since fiscal year 2010, GAO has made 3,409 recommendations to agencies aimed at addressing cybersecurity challenges. As of July 2020, 79 percent of the recommendations have been implemented. Until the remaining recommendations are addressed, agencies' information and IT systems will be increasingly susceptible to the existing multitude of cyber-related threats. Each year, the federal government invests over $90 billion in IT. Even so, IT investments have too often failed or contributed little to mission-related outcomes. Increasingly sophisticated threats and frequent cyber incidents also underscore the need for effective information security. To focus attention on these concerns, GAO has included both the management of IT acquisitions and operations and cybersecurity on its high-risk list. For this statement, GAO summarized its key related reports and assessed agencies' progress in implementing the reports' recommendations. Specifically, GAO reviewed the implementation of recommendations on (1) CIO responsibilities, (2) IT acquisition review requirements, (3) data center consolidation, (4) the management of software licenses, and (5) cybersecurity. Since fiscal year 2010, GAO has made 1,376 recommendations to OMB and agencies to address shortcomings in IT acquisitions and operations, as well as 3,409 recommendations to agencies to improve the security of federal systems. These recommendations addressed, among other things, implementation of CIO responsibilities, oversight of the data center consolidation initiative, management of software licenses, and the efficacy of security programs. Implementing these recommendations is essential to strengthening federal agencies' IT acquisitions, operations, and cybersecurity efforts. For more information, contact Carol C. Harris at (202) 512-4456 or harriscc@gao.gov.

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GAO-20-636R, Survivors of Childhood Cancer: Factors Affecting Access to Follow-up Care, July 31, 2020

Stakeholders GAO interviewed and studies GAO reviewed identified three factors that affect access to follow-up care for childhood cancer survivors—individuals of any age who were diagnosed with cancer from ages 0 through 19. These factors are care affordability, survivors' and health care providers' knowledge of appropriate care, and proximity to care. Childhood cancer survivors need access to follow-up care over time for serious health effects known as late effects—such as developmental problems, heart conditions, and subsequent cancers—which result from their original cancer and its treatment. Affordability: Survivors of childhood cancer may have difficulty paying for follow-up care, which can affect their access to this care. For example, one study found that survivors were significantly more likely to have difficulty paying medical bills and delay medical care due to affordability concerns when compared to individuals with no history of cancer. Knowledge: Survivors' access to appropriate follow-up care for late effects of childhood cancer can depend on both survivors' and providers' knowledge about such care, which can affect access in various ways, according to stakeholders GAO interviewed and studies GAO reviewed: Some survivors may have been treated for cancer at an early age and may have limited awareness of the need for follow- up care. Some primary or specialty care providers may not be knowledgeable about guidelines for appropriate follow-up care, which can affect whether a survivor receives recommended treatment. Follow-up care may include psychosocial care (e.g., counseling), and palliative care (e.g., pain management). Proximity: Survivors may have difficulty reaching appropriate care settings. Stakeholders GAO interviewed and studies GAO reviewed noted that childhood cancer survivors may have to travel long distances to receive follow-up care from multidisciplinary outpatient clinics—referred to as childhood cancer survivorship clinics. The lack of proximity may make it particularly difficult for survivors with limited financial resources to adhere to recommended follow-up care. The National Cancer Institute (NCI) and the Centers for Disease Control and Prevention (CDC)—agencies within the Department of Health and Human Services (HHS) that conduct activities specific to childhood cancer survivors, including research about access to care—have taken steps to implement three provisions in the Childhood Cancer Survivorship, Treatment, Access, and Research Act of 2018 (Childhood Cancer STAR Act) relevant to access to care for survivors. For example, CDC has awarded a contract to develop software to improve the collection of information on individuals with childhood cancer, and NCI has funded three research projects focused on interventions aimed at addressing adverse outcomes among childhood cancer survivors. NCI has also funded research to study the health status and use of follow-up services of 2,000 young adult survivors. Stakeholders have raised questions about the ability of childhood cancer survivors to access needed follow-up care. According to the most recent data available, approximately 465,000 childhood cancer survivors—children, adolescents, and adults—were alive in the United States as of January 1, 2017. Although the 5-year survival rate for childhood cancer has increased from about 62 percent in the mid-1970s to about 86 percent in the mid-2010s, childhood cancer survivors may face late effects, which could require follow-up care across multiple stages of their lives. The conference report accompanying Public Law 115-245 included a provision for GAO to report on barriers to obtaining medical care for childhood cancer survivors, including psychosocial services and palliative care. This report identifies factors reported to affect access to follow-up care for this population. GAO spoke with officials from NCI and CDC and interviewed stakeholders such as providers who care for childhood cancer survivors, professional associations, and advocacy groups. Additionally, GAO reviewed peer-reviewed studies related to access to care for survivors, outcomes of treatment they may receive, and factors that may affect their access to follow-up care. To supplement this work, GAO reviewed the status of selected HHS activities to support access to care for childhood cancer survivors, including steps taken to implement selected provisions in the Childhood Cancer STAR Act. GAO provided a draft of this report to HHS for review and comment. HHS provided technical comments, which GAO incorporated as appropriate. For more information, contact Jessica Farb at (202) 512-7114 or FarbJ@gao.gov.

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GAO-20-593, Genetic Services: Information on Genetic Counselor and Medical Geneticist Workforces, July 31, 2020

Genetic counselors and medical geneticists are two groups who typically work together to provide genetic services, such as genetic testing and counseling. Genetic counselors have at least a master's degree in genetic counseling and assess individuals or families with or at risk for genetic conditions, and provide counseling and education on test results. Medical geneticists are typically physicians who specialize in medical genetics and genomics, and provide comprehensive genetic services, ranging from diagnosis and interpretation of test results to the management and treatment of genetic conditions. GAO's analysis of data from the professional organizations representing this workforce shows the number of genetic counselors certified to provide genetic counseling services has nearly doubled since 2009, and is projected to continue growing. The data show there were approximately 4,700 certified genetics counselors in the United States in 2019. The data also show the number of new medical geneticists has increased modestly since 2009, and the total number certified in the United States was approximately 1,240 as of April 2020. There is no widely accepted measure for how many genetic counselors and medical geneticists should be available; however, representatives from professional organizations GAO interviewed stated that demand for genetic services is rising. Data from the professional organizations representing the genetic counselor and medical geneticist workforces, as well as data from the Census Bureau, also show the number of genetic counselors and medical geneticists varied across states. States averaged seven genetic counselors per 500,000 people in 2019 and two medical geneticists per 500,000 people in 2020. Genetic counselors and medical geneticists primarily practice in hospital settings. Distribution of Genetic Counselors by State, 2019 Advances in genetic technology and research have increased the amount of information available to individuals and providers, and may have increased the demand for genetic services. The medical genetics workforce—which includes genetic counselors and medical geneticists—plays an essential role in providing access to genetic services. Some studies have identified concerns with the size of the medical genetics workforce and its ability to meet the current and future demand for genetic services. A House Committee on Appropriations report included a provision for GAO to conduct an analysis of the medical genetics workforce. This report describes, among other objectives, what is known about changes in the size of the genetic counselor and medical geneticist workforces; and what is known about the geographic distribution of these workforces. GAO reviewed relevant studies of the genetic counselor and medical geneticist workforces; interviewed agency officials and professional organizations representing each workforce; and analyzed the most recent available data on the size and distribution of each workforce in the United States, as well as population data from the Census Bureau. GAO provided a draft of this report to the Department of Health and Human Services and the Department of Labor. The Department of Health and Human Services provided technical comments, which GAO incorporated as appropriate. For more information, contact James Cosgrove at (202) 512-7114 or CosgroveJ@gao.gov.

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