September 11
HHS Needs to Ensure the Availability of Health Screening and Monitoring for All Responders Gao ID: GAO-07-892 July 23, 2007Responders to the World Trade Center (WTC) attack were exposed to many hazards, and concerns remain about long-term health effects of the disaster and the availability of health care services for those affected. In 2006, GAO reported on problems with the Department of Health and Human Services' (HHS) WTC Federal Responder Screening Program and on the Centers for Disease Control and Prevention's (CDC) distribution of treatment funding. GAO was asked to update its 2006 testimony. GAO assessed the status of (1) services provided by the WTC Federal Responder Screening Program, (2) efforts by CDC's National Institute for Occupational Safety and Health (NIOSH) to provide services for nonfederal responders residing outside the New York City (NYC) area, and (3) NIOSH's awards to grantees for treatment services and efforts to estimate service costs. GAO reviewed program documents and interviewed HHS officials, grantees, and others.
HHS's WTC Federal Responder Screening Program has had difficulties ensuring the uninterrupted availability of services for federal responders. From January 2007 to May 2007, the program stopped scheduling screening examinations because there was a change in the administration of the WTC Federal Responder Screening Program, and certain interagency agreements were not established in a timely way to keep the program fully operational. In April 2006 the program also stopped scheduling and paying for specialty diagnostic services because a contract with the program's new provider network did not cover these services. Almost a year later, the contract was modified, and the program resumed scheduling and paying for these services in March 2007. NIOSH is considering expanding the WTC Federal Responder Screening Program to include monitoring--follow-up physical and mental health examinations--and is assessing options for funding and service delivery. If federal responders do not receive monitoring, health conditions that arise later may not be diagnosed and treated, and knowledge of the health effects of the WTC disaster may be incomplete. NIOSH has not ensured the availability of screening and monitoring services for nonfederal responders residing outside the NYC area, although it recently took steps toward expanding the availability of these services. In late 2002, NIOSH arranged for a network of occupational health clinics to provide screening services. This effort ended in July 2004, and until June 2005, NIOSH did not fund screening or monitoring services for nonfederal responders outside the NYC area. In June 2005, NIOSH funded the Mount Sinai School of Medicine Data and Coordination Center (DCC) to provide screening and monitoring services; however, DCC had difficulty establishing a nationwide network of providers and contracted with only 10 clinics in 7 states. In 2006, NIOSH began to explore other options for providing these services, and in May 2007, it took steps toward expanding the provider network. However, these efforts are incomplete. NIOSH has awarded treatment funds to four NYC-area programs, but does not have a reliable cost estimate of serving responders. In fall 2006, NIOSH awarded $44 million for outpatient treatment and set aside $7 million for hospital care. The New York/New Jersey WTC Consortium and the New York City Fire Department WTC program, which received the largest awards, used NIOSH's funding to continue outpatient services, offer full coverage for prescriptions, and cover hospital care. Program officials expect that NIOSH's outpatient treatment awards will be spent by the end of fiscal year 2007. NIOSH lacks a reliable estimate of service costs because the estimate that NIOSH and its grantees developed included potential costs for certain program changes that may not be implemented, and in the absence of actual treatment cost data, they relied on questionable assumptions. It is unclear whether the estimate overstates or understates the cost of serving responders. To improve future cost estimates, HHS officials have required the two largest grantees to report detailed cost data.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-07-892, September 11: HHS Needs to Ensure the Availability of Health Screening and Monitoring for All Responders
This is the accessible text file for GAO report number GAO-07-892
entitled 'September 11: HHS Needs to Ensure the Availability of Health
Screening and Monitoring for All Responders' which was released on July
24, 2007.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
July 2007:
September 11:
HHS Needs to Ensure the Availability of Health Screening and Monitoring
for All Responders:
GAO-07-892:
GAO Highlights:
Highlights of GAO-07-892, a report to congressional requesters
Why GAO Did This Study:
Responders to the World Trade Center (WTC) attack were exposed to many
hazards, and concerns remain about long-term health effects of the
disaster and the availability of health care services for those
affected. In 2006, GAO reported on problems with the Department of
Health and Human Services‘ (HHS) WTC Federal Responder Screening
Program and on the Centers for Disease Control and Prevention‘s (CDC)
distribution of treatment funding.
GAO was asked to update its 2006 testimony. GAO assessed the status of
(1) services provided by the WTC Federal Responder Screening Program,
(2) efforts by CDC‘s National Institute for Occupational Safety and
Health (NIOSH) to provide services for nonfederal responders residing
outside the New York City (NYC) area, and (3) NIOSH‘s awards to
grantees for treatment services and efforts to estimate service costs.
GAO reviewed program documents and interviewed HHS officials, grantees,
and others.
What GAO Found:
HHS‘s WTC Federal Responder Screening Program has had difficulties
ensuring the uninterrupted availability of services for federal
responders. From January 2007 to May 2007, the program stopped
scheduling screening examinations because there was a change in the
administration of the WTC Federal Responder Screening Program, and
certain interagency agreements were not established in a timely way to
keep the program fully operational. In April 2006 the program also
stopped scheduling and paying for specialty diagnostic services because
a contract with the program‘s new provider network did not cover these
services. Almost a year later, the contract was modified, and the
program resumed scheduling and paying for these services in March 2007.
NIOSH is considering expanding the WTC Federal Responder Screening
Program to include monitoring”follow-up physical and mental health
examinations”and is assessing options for funding and service delivery.
If federal responders do not receive monitoring, health conditions that
arise later may not be diagnosed and treated, and knowledge of the
health effects of the WTC disaster may be incomplete.
NIOSH has not ensured the availability of screening and monitoring
services for nonfederal responders residing outside the NYC area,
although it recently took steps toward expanding the availability of
these services. In late 2002, NIOSH arranged for a network of
occupational health clinics to provide screening services. This effort
ended in July 2004, and until June 2005, NIOSH did not fund screening
or monitoring services for nonfederal responders outside the NYC area.
In June 2005, NIOSH funded the Mount Sinai School of Medicine Data and
Coordination Center (DCC) to provide screening and monitoring services;
however, DCC had difficulty establishing a nationwide network of
providers and contracted with only 10 clinics in 7 states. In 2006,
NIOSH began to explore other options for providing these services, and
in May 2007, it took steps toward expanding the provider network.
However, these efforts are incomplete.
NIOSH has awarded treatment funds to four NYC-area programs, but does
not have a reliable cost estimate of serving responders. In fall 2006,
NIOSH awarded $44 million for outpatient treatment and set aside $7
million for hospital care. The New York/New Jersey WTC Consortium and
the New York City Fire Department WTC program, which received the
largest awards, used NIOSH‘s funding to continue outpatient services,
offer full coverage for prescriptions, and cover hospital care. Program
officials expect that NIOSH‘s outpatient treatment awards will be spent
by the end of fiscal year 2007. NIOSH lacks a reliable estimate of
service costs because the estimate that NIOSH and its grantees
developed included potential costs for certain program changes that may
not be implemented, and in the absence of actual treatment cost data,
they relied on questionable assumptions. It is unclear whether the
estimate overstates or understates the cost of serving responders. To
improve future cost estimates, HHS officials have required the two
largest grantees to report detailed cost data.
What GAO Recommends:
GAO recommends that the Secretary of HHS expeditiously ensure that
screening and monitoring services are available for (1) federal
responders and (2) nonfederal responders residing outside the NYC area.
In its comments on a draft of GAO‘s report, HHS said that the report
was generally accurate. HHS did not comment on GAO‘s recommendations.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-892].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia Bascetta at (202)
512-7114 or bascettac@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
WTC Federal Responder Screening Program Has Had Difficulties Ensuring
the Availability of Screening Services and Is Not Designed to Provide
Monitoring:
NIOSH Has Not Ensured the Availability of Services for Nonfederal
Responders Residing outside the NYC Metropolitan Area:
CDC's NIOSH Awarded Funding for Treatment Services to Four WTC Health
Programs, but Does Not Have a Reliable Estimate of Service Costs:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Comments from the Department of Health and Human Services:
Appendix II: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Key Federally Funded WTC Health Programs, June 2007:
Table 2: NIOSH Awards to WTC Health Programs for Providing Treatment
Services, 2006:
Figure:
Figure 1: Timeline of Key Actions Related to the WTC Federal Responder
Screening Program:
Abbreviations:
AOEC: Association of Occupational and Environmental Clinics:
ASPR: Office of the Assistant Secretary for Preparedness and Response:
ATSDR: Agency for Toxic Substances and Disease Registry:
CDC: Centers for Disease Control and Prevention:
DCC: Data and Coordination Center:
EPA: Environmental Protection Agency:
FDNY: New York City Fire Department:
FEMA: Federal Emergency Management Agency:
FOH: Federal Occupational Health Services:
HHS: Department of Health and Human Services:
NIOSH: National Institute for Occupational Safety and Health:
NYC: New York City:
NY/NJ: New York/New Jersey:
NYPD: New York City Police Department:
POPPA: Police Organization Providing Peer Assistance:
PTSD: post-traumatic stress disorder:
WTC: World Trade Center:
United States Government Accountability Office:
Washington, DC 20548:
July 23, 2007:
The Honorable Christopher Shays:
Ranking Member:
Subcommittee on National Security and Foreign Affairs:
Committee on Oversight and Government Reform:
House of Representatives:
The Honorable Vito J. Fossella:
House of Representatives:
The Honorable Carolyn B. Maloney:
House of Representatives:
Tens of thousands of people served as responders in the aftermath of
the World Trade Center (WTC) disaster, including New York City Fire
Department (FDNY) personnel, federal government personnel, and other
government and private-sector workers and volunteers from New York and
elsewhere.[Footnote 1] These responders were exposed to numerous
physical hazards, environmental toxins, and psychological trauma. More
than 5 years after the destruction of the WTC buildings, concerns
remain about the physical and mental health effects of the disaster,
the long-term nature of some of these health effects, and the
availability of health care services for those affected.
Following the WTC attack, federal funding was provided to government
agencies and private organizations to establish programs for screening,
monitoring, or treating responders for illnesses and conditions related
to the WTC disaster; these programs are referred to in this report as
the WTC health programs.[Footnote 2],[Footnote 3] The Department of
Health and Human Services (HHS) funded the programs as separate efforts
serving different categories of responders--for example, firefighters,
other workers and volunteers, or federal responders--and has
responsibility for coordinating program efforts. We have previously
reported on the implementation of these programs and their progress in
providing services to responders,[Footnote 4] who reside in all 50
states and the District of Columbia. In 2005 and 2006, we reported that
one of the WTC health programs, HHS's WTC Federal Responder Screening
Program, which was established to provide onetime screening
examinations for responders who were federal employees when they
responded to the WTC attack, had lagged behind the other programs and
accomplished little.[Footnote 5] HHS established the program in June
2003 and then suspended the program's activities in March 2004, in part
because of difficulties identifying eligible federal responders and
providing any necessary diagnostic services related to responders'
screening examinations. After taking steps to address these concerns,
HHS resumed the program in December 2005; when we testified in
September 2006, we reported that the program was registering and
screening federal responders and that a total of 907 federal workers
had received screening examinations.[Footnote 6] We also reported that
the National Institute for Occupational Safety and Health (NIOSH), a
component of HHS's Centers for Disease Control and Prevention (CDC)
responsible for administering most of the WTC health programs for
responders, had begun to take steps to provide access to screening,
monitoring, and treatment services for nonfederal responders who reside
outside the New York City (NYC) metropolitan area.[Footnote 7]
In September 2006 we also testified that CDC had begun, but not
completed, the process of allocating funding from a $75 million
appropriation made in fiscal year 2006 for WTC health programs for
responders.[Footnote 8],[Footnote 9] This appropriation was available
to provide health care treatment for responders, the first time an
appropriation was specifically available for this purpose. We reported
that in August 2006, CDC had awarded $1.5 million to the FDNY WTC
Medical Monitoring and Treatment Program from this appropriation and
almost $1.1 million to the New York/New Jersey (NY/NJ) WTC Consortium
for treatment-related activities. We also reported that CDC officials
told us they could not predict how long the funding from the
appropriation would support four WTC health programs that provide
treatment services, in part because of uncertainty about the cost of
providing these services.
You requested that we update information provided in our September 2006
testimony. Specifically, in this report we assess the status of (1)
services provided by the WTC Federal Responder Screening Program, (2)
NIOSH's efforts to provide services for nonfederal responders residing
outside the NYC metropolitan area, and (3) NIOSH's awards to grantees
for treatment services, as well as efforts to estimate the cost of
serving responders.
To assess the status of services provided by the WTC Federal Responder
Screening Program, we obtained and reviewed program data and documents
from HHS, including applicable interagency agreements. We interviewed
officials from the HHS entities involved in administering and
implementing the program: NIOSH and two HHS offices, the Federal
Occupational Health Services (FOH)[Footnote 10] and the Office of the
Assistant Secretary for Preparedness and Response (ASPR).[Footnote 11]
To assess the status of NIOSH's efforts to provide services for
nonfederal responders residing outside the NYC metropolitan area, we
obtained documents and interviewed officials from NIOSH. We also
interviewed officials of organizations that worked with NIOSH to
provide or facilitate services for nonfederal responders who reside
outside the NYC metropolitan area, including the Mount Sinai School of
Medicine and the Association of Occupational and Environmental Clinics
(AOEC)--a network of university-affiliated and other private
occupational health clinics across the United States and in Canada. To
assess the status of NIOSH's awards to grantees for treatment services
and efforts to estimate the cost of serving responders, we obtained
documents and interviewed officials from NIOSH, HHS's Office of the
Assistant Secretary for Health, and HHS's Office of the Assistant
Secretary for Planning and Evaluation.[Footnote 12] We also interviewed
officials from two WTC health program grantees[Footnote 13] from which
the majority of responders receive medical services: the NY/NJ WTC
Consortium[Footnote 14] and the FDNY WTC program. In addition, we
interviewed officials from the American Red Cross, which has funded
treatment services for responders. We reviewed a 2007 report submitted
to the mayor of New York City that included an estimate of the cost of
providing health services to responders,[Footnote 15] and we attended a
briefing by a NYC official who participated in compiling that estimate.
To do the work for our review, we relied on information provided by
agency officials and contained in government publications. We compared
the information with information in other supporting documents, when
available, to determine its consistency and reasonableness. We
determined that the information we obtained was sufficiently reliable
for our purposes. We conducted our work from November 2006 through July
2007 in accordance with generally accepted government auditing
standards.
Results in Brief:
HHS's WTC Federal Responder Screening Program has had difficulties
ensuring the uninterrupted availability of services for federal
responders. First, the provision of screening examinations has been
intermittent. After resuming screening examinations in December 2005
and conducting them for about a year, the program again suspended
scheduling of screening examinations for responders from January 2007
to May 2007. This interruption in service occurred because there was a
change in the administration of the WTC Federal Responder Screening
Program, and certain interagency agreements were not established in a
timely way to keep the program fully operational. Second, the program's
provision of specialty diagnostic services by ear, nose, and throat
doctors; cardiologists; and pulmonologists has also been intermittent.
The program did not schedule and pay for these specialty diagnostic
services from April 2006 to March 2007 because the program's contract
with a new provider network did not cover these services. A NIOSH
official told us that NIOSH is considering expanding the WTC Federal
Responder Screening Program to include monitoring examinations-- follow-
up physical and mental health examinations--and is assessing options
for funding and delivering these services. If federal responders do not
receive this type of monitoring, health conditions that arise later may
not be diagnosed and treated, and knowledge of the health effects of
the WTC disaster may be incomplete.
NIOSH has not ensured the availability of screening and monitoring
services for nonfederal responders residing outside the NYC
metropolitan area, although it recently took steps toward expanding the
availability of these services. NIOSH made two initial efforts to
provide screening and monitoring services for these responders. The
first effort, in which NIOSH arranged for AOEC to provide screening
services, began in late 2002 and ended in July 2004. From August 2004
until June 2005, NIOSH did not fund any organization to provide
services to nonfederal responders outside the NYC metropolitan area. In
June 2005, NIOSH began its second effort by awarding funds to the Mount
Sinai School of Medicine Data and Coordination Center (DCC) to provide
both screening and monitoring services. However, DCC had difficulty
establishing a network of providers that could serve responders
residing throughout the country--ultimately contracting with only 10
clinics in 7 states. In early 2006, NIOSH began exploring how to
establish a national program that would expand the network of providers
to provide services for nonfederal responders residing outside the NYC
metropolitan area. However, these efforts are incomplete. In May 2007,
NIOSH and DCC arranged for a national network of providers to screen
and monitor nonfederal responders, and according to DCC officials, the
national network will implement a pilot program consisting of 20
examinations in summer 2007. NIOSH is still investigating how to
provide and pay for treatment services for nonfederal responders who
reside outside the NYC metropolitan area.
CDC's NIOSH awarded and set aside funds totaling $51 million from its
$75 million appropriation for four WTC health programs located in the
NYC metropolitan area to provide treatment services to responders, but
does not have a reliable cost estimate of serving responders. In fall
2006, NIOSH awarded $44 million to four programs to provide outpatient
treatment services to responders enrolled in their programs. NIOSH made
the largest outpatient treatment awards to the two WTC health programs
from which almost all responders receive medical services, the FDNY WTC
program and the NY/NJ WTC Consortium. NIOSH made smaller awards to two
WTC health programs that provide mental health services to members of
the New York City Police Department (NYPD), Project COPE and the Police
Organization Providing Peer Assistance (POPPA) program. The FDNY WTC
program and NY/NJ WTC Consortium used NIOSH's awards to continue to
provide outpatient treatment services and to expand the scope of
treatment by offering full coverage for prescription medications. NIOSH
also set aside $7 million for the FDNY WTC program and NY/NJ WTC
Consortium for providing inpatient hospital care to responders.
Officials from these two programs expect that their awards for
outpatient treatment will be spent by the end of fiscal year 2007.
Efforts by NIOSH and its grantees in 2007 to estimate the cost of
monitoring and treating responders in several of the WTC programs have
not produced reliable results because the estimate included potential
costs for certain program changes that may not be implemented as well
as some costs that were mistakenly included, such as a double counting
of indirect program support costs. In addition, in the absence of
actual treatment cost data, the estimate is based in part on
questionable assumptions. For example, NIOSH and its grantees adjusted
the estimate to account for different treatment utilization levels--the
complexity or volume of care provided to responders based on their
medical needs--but NIOSH and its grantees did not have data to support
the accuracy of the specific cost adjustments they made. It is unclear
whether the 2007 cost estimate overstated or understated the annual
costs of monitoring and treating responders. To improve the reliability
of future cost estimates, HHS officials required the NY/NJ WTC
Consortium and the FDNY WTC program to begin reporting detailed cost
and treatment data, which the programs began submitting in February and
March 2007, respectively.
HHS continues to fund and coordinate the WTC health programs and has
key federal responsibility for ensuring the availability of services to
responders. We are recommending that the Secretary of HHS expeditiously
take action to ensure that screening and monitoring services are
available for all responders, including federal responders and
nonfederal responders residing outside of the NYC metropolitan area.
In commenting on a draft of this report, HHS stated that our report was
generally an accurate and appropriate account of its activities and
accomplishments concerning health services for responders to the WTC
disaster. HHS did not comment on our recommendations.
Background:
When the WTC buildings collapsed on September 11, 2001, an estimated
250,000 to 400,000 people in the vicinity were immediately exposed to a
noxious mixture of dust, debris, smoke, and potentially toxic
contaminants, such as pulverized concrete, fibrous glass, particulate
matter, and asbestos.[Footnote 16] Those affected included people
residing, working, or attending school in the vicinity of the WTC and
emergency responders. In the days, weeks, and months that followed the
attack, tens of thousands of responders were involved in some
capacity.[Footnote 17] These responders included personnel from many
federal, state, and NYC government agencies and private organizations,
as well as volunteers.[Footnote 18]
Health Effects:
A wide variety of physical and mental health effects have been observed
and reported among people who were involved in rescue, recovery, and
cleanup operations and among those who lived and worked in the vicinity
of the WTC buildings.[Footnote 19] Physical health effects included
injuries and respiratory conditions, such as sinusitis, asthma, and a
new syndrome called WTC cough, which consists of persistent coughing
accompanied by severe respiratory symptoms. Almost all firefighters who
responded to the attack experienced respiratory effects, including WTC
cough. One study suggested that exposed firefighters on average
experienced a decline in lung function equivalent to that which would
be produced by 12 years of aging.[Footnote 20] Commonly reported mental
health effects among responders and other affected individuals included
symptoms associated with post-traumatic stress disorder (PTSD),
depression, and anxiety. Behavioral health effects such as alcohol and
tobacco use have also been reported.
Some health effects experienced by responders have persisted or
worsened over time, leading many responders to begin seeking treatment
years after September 11, 2001. Clinicians involved in screening,
monitoring, and treating responders have found that many responders'
conditions--both physical and psychological--have not resolved and have
developed into chronic disorders that require long-term monitoring. For
example, findings from a study conducted by clinicians at the NY/NJ WTC
Consortium show that at the time of examination, up to 2.5 years after
the start of the rescue and recovery effort, 59 percent of responders
enrolled in the program were still experiencing new or worsened
respiratory symptoms.[Footnote 21] Experts studying the mental health
of responders found that about 2 years after the WTC attack, responders
had higher rates of PTSD and other psychological conditions compared to
others in similar jobs who were not WTC responders.[Footnote 22]
Clinicians also anticipate that other health effects, such as
immunological disorders and cancers, may emerge over time. Clinicians
at the FDNY WTC program found an increased incidence of sarcoid-like
pulmonary disease involving inflammation of the lungs. Of 26 cases of
this sarcoid-like pulmonary disease, 13 cases were identified during
the first year after the WTC attack and 13 cases were found during the
next 4 years.[Footnote 23]
Overview of WTC Health Programs:
There are six key programs that currently receive federal funding to
provide voluntary health screening, monitoring, or treatment at no cost
to responders.[Footnote 24] The six WTC health programs, shown in table
1, are (1) the FDNY WTC Medical Monitoring and Treatment Program; (2)
the NY/NJ WTC Consortium, which comprises five clinical centers in the
NY/NJ area;[Footnote 25] (3) the WTC Federal Responder Screening
Program; (4) the WTC Health Registry; (5) Project COPE; and (6) the
POPPA program.[Footnote 26] The programs vary in aspects such as the
HHS administering agency or component responsible for administering the
funding; the implementing agency, component, or organization
responsible for providing program services; eligibility requirements;
and services. Each program uses a variety of approaches, such as Web
sites, toll-free numbers, and community forums, to conduct outreach to
eligible populations.
Table 1: Key Federally Funded WTC Health Programs, June 2007:
Program: FDNY WTC Medical Monitoring and Treatment Program;
HHS administering agency or component: NIOSH;
Implementing agency, component, or organization: FDNY Bureau of Health
Services;
Eligible population: Firefighters and emergency medical service
technicians;
Services provided:
* Initial screening;
* Follow-up medical monitoring;
* Treatment of WTC-related physical and mental health.
Program: NY/NJ WTC Consortium;
HHS administering agency or component: NIOSH;
Implementing agency, component, or organization: Five clinical centers,
one of which, the Mount Sinai-Irving J. Selikoff Center for
Occupational and Environmental Medicine, also serves as the
consortium's DCC;
Eligible population: All responders, excluding FDNY firefighters and
emergency medical service technicians and current federal employees[A];
Services provided:
* Initial screening;
* Follow- up medical monitoring;
* Treatment of WTC-related physical and mental health conditions.
Program: WTC Federal Responder Screening Program;
HHS administering agency or component: NIOSH[B];
Implementing agency, component, or organization: FOH;
Eligible population: Current federal employees who responded to the WTC
attack in an official capacity;
Services provided:
* Onetime screening;
* Referrals to employee assistance programs and specialty diagnostic
services[C].
Program: WTC Health Registry;
HHS administering agency or component: Agency for Toxic Substances and
Disease Registry (ATSDR);
Implementing agency, component, or organization: NYC Department of
Health and Mental Hygiene;
Eligible population: Responders and people living or attending school
in the area of the WTC or working or present in the vicinity on
September 11, 2001;
Services provided:
* Long-term monitoring through periodic surveys.
Program: Project COPE;
HHS administering agency or component: NIOSH;
Implementing agency, component, or organization: Collaboration between
the NYC Police Foundation and Columbia University Medical Center;
Eligible population: NYPD uniformed and civilian employees and their
family members;
Services provided:
* Hotline, mental health counseling, and referral services; some
services provided by Columbia University clinical staff and some by
other clinicians.
Program: POPPA program;
HHS administering agency or component: NIOSH;
Implementing agency, component, or organization: POPPA;
Eligible population: NYPD uniformed employees;
Services provided:
* Hotline, mental health counseling, and referral services; some
services provided by trained NYPD officers and some by mental health
professionals.
Source: GAO analysis of information from NIOSH, ATSDR, FOH, FDNY, NY/NJ
WTC Consortium, NYC Department of Health and Mental Hygiene, POPPA
Program, and Project COPE.
Note: Some of these federally funded programs have also received funds
from the American Red Cross and other private organizations.
[A] In February 2006 ASPR and NIOSH reached an agreement to have former
federal employees screened by the NY/NJ WTC Consortium.
[B] Until December 26, 2006, ASPR was the administrator.
[C] FOH can refer an individual with mental health symptoms to an
employee assistance program for a telephone assessment. If appropriate,
the individual can then be referred to a program counselor for up to
six in-person sessions. The specialty diagnostic services are provided
by ear, nose, and throat doctors; pulmonologists; and cardiologists.
[End of table]
The WTC health programs that are providing screening and monitoring are
tracking thousands of individuals who were affected by the WTC
disaster. As of June 2007, the FDNY WTC program had screened about
14,500 responders and had conducted follow-up examinations for about
13,500 of these responders, while the NY/NJ WTC Consortium had screened
about 20,000 responders and had conducted follow-up examinations for
about 8,000 of these responders. Some of these responders include
nonfederal responders residing outside the NYC metropolitan area. As of
June 2007, the WTC Federal Responder Screening Program had screened
1,305 federal responders and referred 281 responders for employee
assistance program services or specialty diagnostic services. In
addition, the WTC Health Registry, a monitoring program that does not
provide in-person screening or monitoring, but consists of periodic
surveys of self-reported health status and related studies, collected
baseline health data from over 71,000 people who enrolled in the
registry.[Footnote 27] In the winter of 2006, the Registry began its
first adult follow-up survey, and as of June 2007, over 36,000
individuals had completed the follow-up survey.
In addition to providing medical examinations, FDNY's WTC program and
the NY/NJ WTC Consortium have collected information for use in
scientific research to better understand the health effects of the WTC
attack and other disasters. The WTC Health Registry is also collecting
information to assess the long-term public health consequences of the
disaster. Clinicians who evaluate and treat responders to the WTC
disaster told us they expect that research on health effects from the
disaster will not only help researchers understand the health
consequences, but also provide information on appropriate treatment
options for affected individuals.
Federal Funding and Coordination of WTC Health Programs:
Beginning in October 2001 and continuing through 2003, FDNY's WTC
program, the NY/NJ WTC Consortium, the WTC Federal Responder Screening
Program, and the WTC Health Registry received federal funding to
provide services to responders. This funding primarily came from
appropriations to the Department of Homeland Security's Federal
Emergency Management Agency (FEMA),[Footnote 28] as part of the
approximately $8.8 billion that the Congress appropriated to FEMA for
response and recovery activities after the WTC disaster.[Footnote 29]
FEMA entered into interagency agreements with HHS agencies to
distribute the funding to the programs. For example, FEMA entered into
an agreement with NIOSH to distribute $90 million appropriated in 2003
that was available for monitoring.[Footnote 30] FEMA also entered into
an agreement with ASPR for ASPR to administer the WTC Federal Responder
Screening Program. A $75 million appropriation to CDC in fiscal year
2006 for purposes related to the WTC attack resulted in additional
funding for the monitoring activities of the FDNY WTC program, NY/NJ
WTC Consortium, and the Registry.[Footnote 31] The $75 million
appropriation to CDC in fiscal year 2006 also provided funds that were
awarded to the FDNY WTC program, NY/NJ WTC Consortium, Project COPE,
and the POPPA program for treatment services for responders. An
emergency supplemental appropriation to CDC in May 2007 included an
additional $50 million to carry out the same activities provided for in
the $75 million appropriation made in fiscal year 2006.[Footnote 32]
The President's proposed fiscal year 2008 budget for HHS includes $25
million for treatment of WTC-related illnesses for responders.
In February 2006, the Secretary of HHS designated the Director of NIOSH
to take the lead in ensuring that the WTC health programs are well
coordinated, and in September 2006 the Secretary established a WTC Task
Force to advise him on federal policies and funding issues related to
responders' health conditions. The chair of the task force is HHS's
Assistant Secretary for Health, and the vice chair is the Director of
NIOSH. The task force has two subcommittees, one examining finance
issues (cost and financing of WTC-related health programs) and the
other examining the scientific evidence on the health effects of the
WTC disaster. The task force reported to the Secretary of HHS in early
April 2007.
WTC Federal Responder Screening Program Has Had Difficulties Ensuring
the Availability of Screening Services and Is Not Designed to Provide
Monitoring:
HHS's WTC Federal Responder Screening Program has not ensured the
uninterrupted availability of screening services for federal
responders. Since the beginning of the program, the provision of
screening examinations has been intermittent (see fig. 1). After the
program resumed screening examinations in December 2005[Footnote 33]
and conducted them for about a year, HHS again placed the program on
hold in January 2007. From January to May 2007, FOH, the program's
implementing agency, did not schedule screening examinations for
federal responders. This interruption in service occurred because there
was a change in the administration of the WTC Federal Responder
Screening Program, and certain interagency agreements were not
established in a timely way to keep the program fully operational. In
late December 2006, ASPR and NIOSH signed an interagency agreement
giving NIOSH $2.1 million to administer the WTC Federal Responder
Screening Program.[Footnote 34] Subsequently, NIOSH and FOH needed to
sign a new interagency agreement to allow FOH to continue to be
reimbursed for providing screening examinations. It took several months
for the agreement between NIOSH and FOH to be negotiated and
approved.[Footnote 35] After both agencies signed the agreement, FOH
resumed scheduling screening examinations for federal responders in May
2007. At that time, there were 28 federal responders waiting to be
scheduled for screening examinations.
Figure 1: Timeline of Key Actions Related to the WTC Federal Responder
Screening Program:
[See PDF for image]
Source: GAO analysis of information from ASPR, FOH, NIOSH, and FEMA.
Note: The WTC Federal Responder Screening Program serves current
federal employees who responded to the WTC attack in an official
capacity. In February 2006, ASPR and NIOSH reached an agreement to have
former federal employees screened by the NY/NJ WTC Consortium.
[A] In December 2006 the Office of Public Health and Emergency
Preparedness became ASPR. We refer to that office as ASPR throughout
this figure, regardless of the time period being discussed.
[B] In providing referrals for specialty diagnostic services, FOH
schedules and pays for the diagnostic service.
[C] After HHS placed the program on hold, FOH completed examinations
that had already been scheduled.
[End of figure]
The WTC Federal Responder Screening Program's provision of specialty
diagnostic services has also been intermittent. The health effects
experienced by responders often result in a need for diagnostic
services by ear, nose, and throat doctors; cardiologists; and
pulmonologists. When these diagnostic services are needed after the
initial screening examination, FOH refers responders to these
specialists and pays for the services.[Footnote 36] The WTC Federal
Responder Screening Program stopped scheduling and paying for these
specialty diagnostic services for almost a year, from April 2006 to
March 2007. This occurred because in April 2006, FOH contracted with a
new provider network to provide various services for federal employees,
such as immunizations and vision tests. The contract with the new
provider network did not cover specialty diagnostic services by ear,
nose, and throat doctors; cardiologists; and pulmonologists. Although
the previous provider network had provided these services, the new
provider network and the HHS contract officer interpreted the statement
of work in the new contract as not including these specialty diagnostic
services. FOH was therefore unable to pay for these services for
federal responders and stopped scheduling them in April 2006. Almost a
year later, in March 2007, FOH modified its contract with the provider
network and resumed scheduling and paying for specialty diagnostic
services for federal responders. FOH estimated that at that time, 104
responders were waiting for appointments for these services.
The WTC Federal Responder Screening Program was designed to provide a
onetime screening examination; however, NIOSH officials told us they
want to expand the program to offer monitoring examinations--that is,
follow-up physical and mental health examinations--to federal
responders.[Footnote 37] Clinicians involved in the monitoring of
responders have noted the need for long-term monitoring because some
possible health effects, such as cancer, may not appear until many
years after a person has been exposed to a harmful agent. NIOSH
officials have said that to expand the WTC Federal Responder Screening
Program to include monitoring, NIOSH would need to secure funding and
determine who would provide the monitoring services. A NIOSH official
told us that one option for funding would be for NIOSH to use some of
the $2.1 million of the existing FEMA-ASPR funding to have the WTC
Federal Responder Screening Program include monitoring. For this to
happen, the NIOSH official said, FEMA, which originally provided the
funding to ASPR to establish the program, would have to agree to change
the scope of the program. In February 2007, NIOSH sent a letter to FEMA
asking whether the funding for the program could be provided directly
to NIOSH and whether the funding could be used to support monitoring in
addition to the onetime screening examination the program currently
offers, but as of June 2007, NIOSH had not received a response from
FEMA. NIOSH officials told us that if FEMA does not agree to this
arrangement, NIOSH will consider using other funding to pay for
monitoring. According to a NIOSH official, if NIOSH either reaches a
new agreement with FEMA or decides to pay for monitoring of federal
responders by itself, NIOSH would have to either negotiate a new
agreement with FOH to provide monitoring, which FOH officials said they
would consider doing, or it would have to make arrangements with
another program, such as the NY/NJ WTC Consortium, to provide
monitoring.
NIOSH Has Not Ensured the Availability of Services for Nonfederal
Responders Residing outside the NYC Metropolitan Area:
NIOSH has not ensured the availability of screening and monitoring
services for nonfederal responders residing outside the NYC
metropolitan area, although it recently took steps toward expanding the
availability of these services. NIOSH made two initial efforts to
provide screening and monitoring services for these responders. The
first effort, in which NIOSH arranged for AOEC to provide screening
services, began in late 2002 and ended in July 2004. From August 2004
until June 2005, NIOSH did not fund any organization to provide
services to nonfederal responders outside the NYC metropolitan area. In
June 2005, NIOSH began its second effort by awarding funds to Mount
Sinai's DCC to provide both screening and monitoring services. However,
DCC had difficulty establishing a network of providers that could serve
nonfederal responders residing throughout the country. In early 2006,
NIOSH began exploring how to establish a broader national program that
would provide screening and monitoring services, as well as treatment,
for nonfederal responders residing outside the NYC metropolitan area.
However, these efforts are incomplete. In May 2007, NIOSH and DCC
arranged for a national network of providers to screen and monitor
nonfederal responders, and a pilot program consisting of 20
examinations was scheduled to begin in summer 2007.
NIOSH's Initial Efforts to Provide Screening and Monitoring Services
for Nonfederal Responders Residing outside the NYC Area Did Not Ensure
Availability of These Services:
In November 2002, NIOSH began its first effort to provide services for
nonfederal responders outside the NYC metropolitan area.[Footnote 38]
The exact number of these responders is unknown.[Footnote 39] NIOSH
awarded a contract for about $306,000 to the Mount Sinai School of
Medicine to provide screening services for nonfederal responders
residing outside the NYC metropolitan area and directed it to establish
a subcontract with AOEC. AOEC then subcontracted with 32 of its member
clinics across the country to provide screening services. For its part,
AOEC was responsible for establishing a network of providers nationwide
through its member clinics, referring nonfederal responders to the AOEC
member clinics for screening examinations, working with Mount Sinai to
determine responders' program enrollment eligibility, ensuring proper
billing, and reimbursing its member clinics for services. From February
2003 to July 2004, the 32 AOEC member clinics screened 588 nonfederal
responders nationwide.
An AOEC official told us AOEC experienced challenges in providing the
screening services nationwide through its member clinics. This official
said, for example, that many nonfederal responders--especially those
residing in rural areas--did not enroll in the program because they did
not live near an AOEC member clinic. In addition, the process to
reimburse AOEC member clinics for clinical examinations required
substantial coordination among AOEC, AOEC member clinics, and Mount
Sinai. After a nonfederal responder was examined by an AOEC member
clinic, Mount Sinai had to review the responder's medical records and
determine that all aspects of the examination were completed before
AOEC could issue a payment to its member clinic.
From August 2004 until June 2005, NIOSH did not fund any organization
to provide screening or monitoring services outside the NYC
metropolitan area for nonfederal responders. Mount Sinai's subcontract
with AOEC to provide screening services ended in July 2004 when NIOSH
was establishing cooperative agreements to provide both screening and
monitoring services for nonfederal responders nationwide. A NIOSH
official told us that from July 2004 until June 2005, NIOSH focused on
providing screening and monitoring services for nonfederal responders
in the NYC metropolitan area because the majority of nonfederal
responders reside there. NIOSH had requested applications from
organizations to provide both screening and monitoring services for
nonfederal responders and awarded funds to the FDNY WTC program and NY/
NJ WTC Consortium to provide these services in the NYC metropolitan
area. AOEC applied to use its national network of member clinics to
provide screening and monitoring for nonfederal responders residing
outside the NYC metropolitan area, but NIOSH rejected AOEC's
application.[Footnote 40] AOEC was the only organization that applied
to provide screening and monitoring services to these responders.
In June 2005, NIOSH began its second effort to provide services for
nonfederal responders residing outside the NYC metropolitan area.
Specifically, NIOSH awarded about $776,000 to DCC to coordinate the
provision of screening and monitoring services for these
responders.[Footnote 41] DCC spent about $387,000 of these funds on
providing screening and monitoring services for these responders. In
June 2006, NIOSH awarded an additional $788,000 to DCC to provide
screening and monitoring services for nonfederal responders residing
outside the NYC metropolitan area.[Footnote 42] According to a NIOSH
official, DCC budgeted about $393,000 of the $788,000 for providing
these services, and received approval from NIOSH to redirect the
remaining amount ($395,000) for other purposes. NIOSH officials told us
that they assigned DCC the task of providing screening and monitoring
services to nonfederal responders outside the NYC metropolitan area
because the task was consistent with DCC's responsibilities for the NY/
NJ WTC Consortium, which include data monitoring and coordination. DCC,
however, had difficulty establishing a network of providers that could
serve nonfederal responders residing throughout the country--
ultimately contracting with only 10 clinics in 7 states to provide
screening and monitoring services.[Footnote 43] DCC officials said that
as of June 2007, the 10 clinics were monitoring 180 responders.
According to a NIOSH official, there have been several challenges
involved in establishing a network of providers to screen and monitor
nonfederal responders nationwide. These include establishing contracts
with clinics that have the occupational health expertise to provide
services nationwide, establishing patient data transfer systems that
comply with applicable privacy laws, navigating the institutional
review board[Footnote 44] process for a large provider network, and
establishing payment systems with clinics participating in a national
network of providers.
NIOSH Has Recently Taken Steps to Establish a National Program for
Nonfederal Responders to Provide Screening, Monitoring, and Treatment
Services, but Its Efforts Are Incomplete:
Since 2006, NIOSH has been exploring how to establish a national
program that would expand the availability of screening and monitoring
services, as well as provide treatment services, to nonfederal
responders residing outside the NYC metropolitan area.[Footnote 45]
NIOSH officials have indicated that they would like to expand the
availability of screening and monitoring services by establishing a
network of providers with locations convenient to all nonfederal
responders. NIOSH officials have also indicated that they would like to
offer the same set of services to these responders that is offered to
nonfederal responders in the NYC metropolitan area--screening,
monitoring, and treatment services. NIOSH has considered different
approaches for this national program. For example, in early 2006, NIOSH
officials considered funding AOEC and its network of 50 member clinics
to administer a national program and instructed DCC to discontinue
efforts to establish new contracts with clinics nationwide. However, in
February 2007, NIOSH officials decided that AOEC would not administer
the national program.[Footnote 46] On March 15, 2007, NIOSH issued a
formal request for information from organizations that have an interest
in and the capability of developing a national program for responders
residing outside the NYC metropolitan area.[Footnote 47] In this
request, NIOSH described the scope of a national program as offering
screening, monitoring, and treatment services to about 3,000 nonfederal
responders through a national network of occupational health
facilities. NIOSH also specified that the program's facilities should
be located within reasonable driving distance to responders and that
participating facilities must provide copies of examination records to
DCC.
In May 2007, NIOSH took steps toward establishing the national program,
but its efforts are incomplete. NIOSH approved a request from DCC to
redirect about $125,000 from the June 2006 award to establish a
contract with a company to provide screening and monitoring services
for nonfederal responders residing outside the NYC metropolitan area.
Subsequently, DCC contracted with QTC Management, Inc.,[Footnote 48]
one of the four organizations that had responded to NIOSH's request for
information. QTC has a network of providers located across all 50
states and the District of Columbia and will use internal medicine and
occupational medicine doctors in its network to provide these services.
In addition, QTC will identify and subcontract with providers outside
of the QTC network to screen and monitor nonfederal responders who do
not reside within 25 miles of a QTC provider.[Footnote 49] In June
2007, NIOSH awarded $800,600 to DCC for coordinating the provision of
screening and monitoring examinations, and QTC will receive a portion
of this award from DCC to provide about 1,000 screening and monitoring
examinations through May 2008.[Footnote 50] According to DCC officials,
they are working with QTC to establish examination protocols and
administrative systems needed to begin conducting screening and
monitoring examinations, and they will begin a pilot program consisting
of 20 examinations in summer 2007. DCC's contract with QTC does not
include treatment services, and NIOSH officials are still exploring how
to provide and pay for treatment services for nonfederal responders
residing outside the NYC metropolitan area.[Footnote 51]
CDC's NIOSH Awarded Funding for Treatment Services to Four WTC Health
Programs, but Does Not Have a Reliable Estimate of Service Costs:
In fall 2006, CDC's NIOSH awarded $44 million to four programs in the
NYC metropolitan area for providing outpatient treatment services to
responders. Officials from the FDNY WTC program and NY/NJ WTC
Consortium used some of the funds to provide full coverage for
prescription medications. NIOSH also set aside $7 million for the FDNY
WTC program and NY/NJ WTC Consortium to provide inpatient hospital
care. Officials from these programs expect that the funds they received
from NIOSH for outpatient services will be spent by the end of fiscal
year 2007. NIOSH has worked with two of its grantees to estimate the
cost of monitoring and treating responders; however, the most recent
effort, in 2007, has not produced reliable results because the estimate
included potential costs for certain program changes that may not be
implemented as well as some costs that reduced the estimate's accuracy.
In addition, in the absence of actual treatment cost data, the estimate
was based in part on questionable assumptions. To improve the
reliability of future cost estimates, HHS officials have required some
of the WTC health programs to report detailed cost and treatment data.
NIOSH Awarded $44 Million in Outpatient Treatment Funding, Which Is
Expected to Be Spent by End of Fiscal Year 2007, and Set Aside $7
Million for Hospital Care:
In fall 2006, NIOSH awarded and set aside funds totaling $51 million
from its $75 million appropriation for four WTC health programs in the
NYC metropolitan area to provide treatment services to responders
enrolled in these programs.[Footnote 52] Of the $51 million, NIOSH
awarded about $44 million for outpatient services to the FDNY WTC
program, the NY/NJ WTC Consortium, Project COPE, and the POPPA program.
NIOSH made the largest awards to the two programs from which almost all
responders receive medical services, the FDNY WTC program and NY/NJ WTC
Consortium (see table 2). Officials from the FDNY WTC program and NY/NJ
WTC Consortium expect funds they received from NIOSH for outpatient
treatment services to be expended by the end of fiscal year
2007.[Footnote 53] In addition to the $44 million it awarded for
outpatient services, NIOSH set aside about $7 million for the FDNY WTC
program and NY/NJ WTC Consortium to pay for responders' WTC-related
inpatient hospital care as needed.[Footnote 54]
Table 2: NIOSH Awards to WTC Health Programs for Providing Treatment
Services, 2006:
WTC health program: NY/NJ WTC Consortium;
Amount of award[A] (in millions): $20.8;
Date of award: October 26, 2006.
WTC health program: FDNY WTC Medical Monitoring and Treatment Program;
Amount of award[A] (in millions): 18.7;
Date of award: October 26, 2006.
WTC health program: Project COPE;
Amount of award[A] (in millions): 3.0[B];
Date of award: September 19, 2006.
WTC health program: POPPA program;
Amount of award[A] (in millions): 1.5[C];
Date of award: September 19, 2006.
WTC health program: Total amount of awards;
Amount of award[A] (in millions): $44.0;
Date of award: [Empty].
Source: NIOSH.
[A] Amount is rounded to the nearest $0.1 million.
[B] NIOSH will provide $1 million annually to Project COPE beginning in
September 2006 through September 2008, for a total award of $3 million.
[C] NIOSH will provide $500,000 annually to the POPPA program beginning
in September 2006 through September 2008, for a total award of $1.5
million.
[End of table]
The FDNY WTC program and NY/NJ WTC Consortium used their awards from
NIOSH to continue providing treatment services to responders and to
expand the scope of available treatment services. Before NIOSH made its
awards for treatment services, the treatment services provided by the
two programs were supported by funding from private philanthropies and
other organizations. According to officials of the NY/NJ WTC
Consortium, this funding was sufficient to provide only outpatient care
and partial coverage for prescription medications. The two programs
used NIOSH's awards to continue to provide outpatient services to
responders, such as treatment for gastrointestinal reflux disease,
upper and lower respiratory disorders, and mental health conditions.
They also expanded the scope of their programs by offering responders
full coverage for their prescription medications for the first time. A
NIOSH official told us that some of the commonly experienced WTC
conditions, such as upper airway conditions, gastrointestinal
disorders, and mental health disorders, are frequently treated with
medications that can be costly and may be prescribed for an extended
period of time. According to an FDNY WTC program official, prescription
medications are now the largest component of the program's treatment
budget.
The FDNY WTC program and NY/NJ Consortium also expanded the scope of
their programs by paying for inpatient hospital care for the first
time, using funds from the $7 million that NIOSH had set aside for this
purpose. According to a NIOSH official, NIOSH pays for hospitalizations
that have been approved by the medical directors of the FDNY WTC
program and NY/NJ WTC Consortium through awards to the programs from
the funds NIOSH set aside for this purpose. As of June 1, 2007, there
were 15 hospitalizations of responders, 13 of whom were referred by the
NY/NJ WTC Consortium's Mount Sinai clinic and 2 by the FDNY WTC
program. Responders have received inpatient hospital care to treat, for
example, asthma, pulmonary fibrosis,[Footnote 55] and severe cases of
depression or PTSD. If not completely used by the end of fiscal year
2007, funds set aside for hospital care could be used for outpatient
services.
After receiving NIOSH's funding for treatment services in fall 2006,
the NY/NJ WTC Consortium ended its efforts to obtain reimbursement from
health insurance held by responders with coverage.[Footnote 56]
Consortium officials told us that efforts to bill insurance companies
involved a heavy administrative burden and were frequently
unsuccessful, in part because the insurance carriers typically denied
coverage for work-related health conditions on the grounds that such
conditions should be covered by state workers' compensation programs.
However, according to officials from the NY/NJ WTC Consortium,
responders trying to obtain workers' compensation coverage routinely
experienced administrative hurdles and significant delays, some lasting
several years. Moreover, according to these program officials, the
majority of responders enrolled in the program either had limited or no
health insurance coverage. According to a labor official, responders
who carried out cleanup services after the WTC attack often did not
have health insurance, and responders who were construction workers
often lost their health insurance when they became too ill to work the
number of days each quarter or year required to maintain eligibility
for insurance coverage.
NIOSH and Its Grantees Have Estimated Costs of Providing Monitoring and
Treatment Services, but These Efforts Have Not Produced a Reliable
Estimate:
NIOSH has worked with two of its grantees--the FDNY WTC program and NY/
NJ WTC Consortium--to estimate the annual cost of monitoring and
treating responders. In December 2006, the agency and its grantees
estimated that the annual cost of monitoring and treating responders
enrolled in the FDNY WTC program and NY/NJ WTC Consortium, including
associated program costs,[Footnote 57] was about $257 million. In
January 2007, NIOSH revised the estimate to also include the cost of
monitoring and treating responders enrolled in the WTC Federal
Responder Screening Program and nonfederal responders residing outside
the NYC metropolitan area who participate in the WTC health programs.
The estimate did not include the cost of providing mental health
treatment services through Project COPE and the POPPA program.[Footnote
58] The January 2007 estimate projected that aggregate annual costs for
providing monitoring and treatment services, along with associated
program expenses, could be approximately $230 million or $283 million,
depending on the number of responders who receive treatment
services.[Footnote 59]
To develop an estimate of outpatient treatment costs, which are
generally higher than monitoring costs, NIOSH and its grantees
projected the incidence of WTC-related health conditions among
responders and the number of responders who would likely obtain
treatment. Based on this number, they projected that in a given year,
* 25 to 30 percent of participating responders will have aerodigestive
(combined pulmonary and gastrointestinal) disorders that require
treatment,
* 25 to 35 percent of participating responders will have mental health
disorders that require treatment, and:
* 1 to 4 percent of participating responders will have musculoskeletal
disorders that require treatment.
To estimate treatment costs for these conditions, NIOSH and its
grantees multiplied the estimated per patient cost of providing
outpatient services by the number of responders projected to need these
services in a given year. They did not have actual cost data on these
services because the WTC health programs had not been required to
report such data when private organizations were funding the programs'
treatment services. In the absence of actual cost data, NIOSH and its
grantees relied on workers' compensation reimbursement rates for
specific services[Footnote 60] as a proxy for outpatient treatment
costs. They adjusted the proxy rates to reflect different treatment
utilization[Footnote 61] levels--routine, moderate, or extensive
outpatient care--and used their best judgment, based on experience, for
the distribution of responders into the three treatment utilization
levels. Specifically, they used the proxy rates to represent moderate
utilization, reduced the proxy rates by one-third to represent routine
utilization, and increased the proxy rates by one-third to represent
extensive outpatient care. Outpatient treatment costs were further
adjusted to account for the differences in treatment protocols and
medication costs at the FDNY WTC program and NY/NJ WTC
Consortium.[Footnote 62] After estimating the cost of providing
outpatient services, NIOSH and its grantees estimated other treatment-
related expenses--inpatient care, medical monitoring, indirect
costs,[Footnote 63] language translation, data analysis, and expenses
incurred by NIOSH such as for travel and telephone service. They added
these estimated expenses to the estimate for outpatient services to
arrive at a total annual cost amount.
Several factors reduced the reliability of the January 2007 estimate.
It is unclear whether the overall estimate overstated or understated
the costs of monitoring and treating responders. First, the estimate
included potential costs that reflect certain program changes that may
not be implemented. For example, when NIOSH and its grantees projected
the cost of medically monitoring responders, the estimate assumed a
more frequent monitoring interval, which has been discussed by program
officials but has not been adopted.[Footnote 64] Similarly, they
included costs for providing monitoring and treatment services to
federal responders, who are not now eligible for such services.
Second, NIOSH mistakenly included certain costs in the estimate.
According to NIOSH officials, the estimate included a calculation for
indirect costs associated with monitoring and treating responders.
However, NIOSH officials later learned that the workers' compensation
reimbursement rates that were used as a proxy for outpatient treatment
costs already contained an adjustment for indirect costs. As a result,
total indirect costs were overstated. In addition, the estimate
included the cost of monitoring services provided by the FDNY WTC
program and NY/NJ WTC Consortium without taking into account that these
services were already funded through mid-2009 by other NIOSH funds.
Finally, in the absence of actual data on the cost of providing
treatment services, the estimate was based in part on two questionable
assumptions. First, when NIOSH and its grantees used the assumption
that adjusting the proxy rates up or down by one-third would account
for the differences in treatment utilization levels, there were no data
to support the accuracy of such adjustments. As a result, it is unclear
whether the projections of treatment costs have resulted in an
overestimate or underestimate of treatment costs. Second, the
assumption used to estimate the cost of medical monitoring was not
consistent with the historical participation rates reported by the NY/
NJ WTC Consortium. NIOSH and its grantees based the estimate on the
assumption that every responder would keep his or her appointment for
periodic medical monitoring. However, NY/NJ WTC Consortium officials
told us that the rate at which responders have kept scheduled
appointments is 50 to 60 percent.[Footnote 65]
HHS Officials Have Taken Steps to Develop More Reliable Cost Estimates:
To improve the reliability of future efforts to estimate the cost of
providing services to responders, NIOSH officials and the Assistant
Secretary for Health--in his capacity as chairman of the HHS WTC Task
Force--have required the FDNY WTC program and NY/NJ WTC Consortium to
report detailed demographic, service utilization, and cost information.
The information requested from each program includes:
* the number of responders monitored and treated,
* diagnoses of responders monitored and treated,
* medical services provided and the cost of those services, and:
* responders' occupations and insurance coverage status.
These data are to be reported on a quarterly basis, and the first
reports were received from the NY/NJ WTC Consortium in late February
2007 and from the FDNY WTC program in March 2007. These reports
included data covering 2 quarters--July through September 2006, when
treatment funding was provided by the American Red Cross, and October
through December 2006, when treatment funding was provided by NIOSH and
the American Red Cross.[Footnote 66]
According to an HHS official who is a member of the HHS WTC Task Force,
some of the cost reports submitted in February and March were
incomplete and therefore did not provide sufficient information to
support a reliable estimate of the annual cost of medical services
provided by the WTC health programs. For example, some clinical centers
submitted expense reports for only 1 quarter instead of 2. Furthermore,
a NIOSH official told us that some of the data that were compiled
manually were not accurate. According to the task force member, HHS
will need at least 4 quarters of complete and accurate data before it
can make reliable estimates. This would mean that HHS may not have data
needed to develop a reliable estimate of costs until October 2008.
NIOSH officials told us, however, that as they, the FDNY WTC program,
and the NY/NJ WTC Consortium gain experience and as report data are
automated, the quality of the data they develop and the reliability of
cost estimates will improve.
Conclusions:
Screening and monitoring the health of the people who responded to the
September 11, 2001, attack on the World Trade Center are critical for
identifying health effects already experienced by responders or those
that may emerge in the future. In addition, collecting and analyzing
information produced by screening and monitoring responders can give
health care providers information that could help them better diagnose
and treat responders and others who experience similar health effects.
While some groups of responders are eligible for screening and follow-
up physical and mental health examinations through the federally funded
WTC health programs, other groups of responders are not eligible for
comparable services or may not always find these services available.
Federal responders are eligible only for the initial screening
examination provided through the WTC Federal Responder Screening
Program and are not eligible for federally funded follow-up monitoring
examinations. In addition, many responders who reside outside of the
NYC metropolitan area have not been able to obtain screening and
monitoring services because available services are too distant.
Moreover, HHS has repeatedly interrupted the programs it established
for federal responders and nonfederal responders outside of NYC,
resulting in periods when no services were available to them.
HHS continues to fund and coordinate the WTC health programs and has
key federal responsibility for ensuring the availability of services to
responders. HHS and its agencies have recently taken steps to move
toward providing screening and monitoring services to federal
responders and to nonfederal responders living outside of the NYC area.
However, these efforts are not complete, and the stop-and-start history
of the department's efforts to serve these groups does not provide
assurance that the latest efforts to extend screening and monitoring
services to these responders will be successful and will be sustained
over time. Therefore, it is important for HHS to make a concerted
effort, without further delay, to ensure that health screening and
monitoring services are available to all people who responded to the
attack on the World Trade Center, regardless of who their employer is
or where they reside.
Recommendations for Executive Action:
To ensure that comparable screening and monitoring services are
available to all responders, we are recommending that the Secretary of
HHS expeditiously take two actions: (1) ensure that screening and
monitoring services are available for federal responders and (2) ensure
that screening and monitoring services are available for nonfederal
responders residing outside of the NYC metropolitan area.
Agency Comments and Our Evaluation:
HHS reviewed a draft of this report and provided comments, which are
reprinted in appendix I. HHS also provided technical comments, which we
incorporated as appropriate.
HHS commented that overall, our report is an accurate and appropriate
account of its activities and accomplishments concerning health
services for responders to the WTC disaster. However, HHS stated that
an inaccurate understanding of our findings would likely result if a
reader read only the summary information about the WTC Federal
Responder Screening Program and services for nonfederal responders
residing outside the NYC area in the Highlights and Results in Brief.
Where appropriate, we revised the language in the Highlights and
Results in Brief to be consistent with the findings in our report. HHS
also stated that our description of the services available to
nonfederal responders residing outside the NYC metropolitan area did
not acknowledge that over 60 percent of these responders have been
examined by the DCC network or by AOEC. However, because the total
number of nonfederal responders residing outside the NYC metropolitan
area is unknown, we believe it is not possible to determine what
percentage of these responders has been examined.
In its comments, HHS raised concerns about our use of the terms HHS,
CDC, and NIOSH with respect to their role in particular activities. We
modified the report where appropriate to clarify respective agency
responsibilities. Finally, HHS acknowledged that the estimate of the
costs of monitoring and treating WTC responders was imprecise. HHS also
noted, as we have reported, that the clinical centers of the NY/NJ WTC
Consortium and the FDNY WTC program have begun submitting quarterly
cost and treatment reports and that this information will be used to
improve cost estimates. We believe this is an important step toward the
development of a reliable estimate.
HHS did not comment on our recommendations.
As agreed with your offices, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its issue date. At that time we will send copies of this report
to the Secretary of Health and Human Services, congressional
committees, and other interested parties. We will also make copies
available to others upon request. In addition, the report will be
available at no charge on the GAO Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please
contact me at (202) 512-7114 or bascettac@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix II.
Signed by:
Cynthia Bascetta:
Director, Health Care:
[End of section]
Appendix I: Comments from the Department of Health and Human Services:
Office of the Assistant Secretary for Legislation:
Department Of Health & Human Services:
Washington, D.C. 20201:
Jul 16 2007:
Cynthia Bascetta:
Director:
Health Care:
U.S. Government Accountability Office:
Washington, DC 20548:
Dear Ms. Bascetta:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO) raft report entitled, "HHS Needs to
Ensure the Availability of Health Screening and Monitoring for All
Responders" (GAO-07-892).
The Department has provided several technical comments directly to your
staff.
The Department appreciates the opportunity to comment on this draft
before its publication.
Sincerely,
Signed by:
Vincent Ventimiglia:
Assistant Secretary for Legislation:
Comments From The U.S. Department Of Health And Human Services (HHS) On
The U.S. Government Accountability Office's (GAO) Draft Report: HHS
Needs To Ensure The Availability Of Health Screening And Monitoring For
All Responders (GAO-07-892):
General Comments:
While the entire report is generally an accurate and appropriate
account of activities and accomplishments, the "Highlights" page and
the "Results in Brief' do not provide the same degree of objectivity.
As an example, in the first paragraph of the Highlights, the second
sentence ends with the words: ". to keep the program operational."
However, the same sentence on page 17 is worded: ". to keep the program
fully operational." Similarly, the first sentence in paragraph two
states: "NIOSH has not ensured the availability of screening and
monitoring services for nonfederal responders residing outside the NYC
area." However, over 60% of such responders have been examined either
by the DCC network or by AOEC, and there is now a mechanism in place
for these examinations. Thus, if a reader only looks at the summary
information, an inaccurate understanding will likely result.
References to HHS, CDC, and NIOSH are sometimes mismatched with respect
to certain activities. For the most part, NIOSH has served as the
primary operational component for this program. However, NIOSH has had
interactions with CDC offices and other HHS components, as well as
FEMA, in the conduct of this program. In most places, it would be more
accurate to refer to CDC/NIOSH" rather than either "CDC" or "NIOSH"
separately.
Cost estimates were based on grantee information and are unquestionably
imprecise. NIOSH has required all six clinical centers to report their
expenses and their patient numbers on a quarterly basis in order to
monitor the progress of the program. This information, along with other
information on medical protocols is being used to improve cost
estimates.
[End of section]
Appendix II: GAO Contact and Staff Acknowledgments:
GAO Contact:
Cynthia A. Bascetta, (202) 512-7114 or bascettac@gao.gov:
Acknowledgments:
In addition to the contact named above, Helene F. Toiv, Assistant
Director; George Bogart; Hernan Bozzolo; Frederick Caison; Anne
Dievler; and Krister Friday made key contributions to this report.
FOOTNOTES
[1] In this report, "responders" refers to anyone involved in rescue,
recovery, or cleanup activities at or near the vicinity of the WTC or
Staten Island site, the landfill that is the off-site location of the
WTC recovery operation.
[2] In this report, "screening" refers to initial physical and mental
health examinations of responders. "Monitoring" refers to tracking the
health of responders over time, either through periodic surveys or
through follow-up physical and mental health examinations.
[3] One of the WTC health programs, the WTC Health Registry, also
includes people living or attending school in the area of the WTC or
working or present in the vicinity on September 11, 2001.
[4] GAO, September 11: HHS Has Screened Additional Federal Responders
for World Trade Center Health Effects, but Plans for Awarding Funds for
Treatment Are Incomplete, GAO-06-1092T (Washington, D.C.: Sept. 8,
2006); September 11: Monitoring of World Trade Center Health Effects
Has Progressed, but Program for Federal Responders Lags Behind, GAO-06-
481T (Washington, D.C.: Feb. 28, 2006); September 11: Monitoring of
World Trade Center Health Effects Has Progressed, but Not for Federal
Responders, GAO-05-1020T (Washington, D.C.: Sept. 10, 2005); and
September 11: Health Effects in the Aftermath of the World Trade Center
Attack, GAO-04-1068T (Washington, D.C.: Sept. 8, 2004).
[5] See GAO-05-1020T and GAO-06-481T.
[6] See GAO-06-1092T.
[7] In general, the WTC health programs provide services in the NYC
metropolitan area.
[8] Department of Defense Appropriations Act, 2006, Pub. L. No. 109-
148, § 5011(b), 119 Stat. 2680, 2814 (2005).
[9] See GAO-06-1092T.
[10] FOH is a service unit within HHS's Program Support Center that
provides occupational health services to federal government departments
and agencies located throughout the United States.
[11] ASPR coordinates and directs HHS's emergency preparedness and
response program. In December 2006, the Office of Public Health and
Emergency Preparedness became ASPR. We refer to that office as ASPR
throughout this report, regardless of the time period discussed.
[12] The Assistant Secretary for Health is chief public health advisor
for the Secretary of HHS; the Assistant Secretary for Planning and
Evaluation is the principal advisor to the Secretary on policy
development and is responsible for major activities in policy
coordination, legislation development, strategic planning, policy
research, evaluation, and economic analysis.
[13] NIOSH provides funds to the programs through cooperative
agreements, but refers to award recipients as grantees. Therefore, in
this report we use the term grantee when referring to NIOSH's award
recipients.
[14] In previous reports we have also referred to this program as the
worker and volunteer WTC Program.
[15] See World Trade Center Health Panel, Addressing the Health Impacts
of 9-11: Report and Recommendations to Mayor Michael R. Bloomberg (New
York: January 2007).
[16] More than 20,000 residences in Lower Manhattan may have been
affected by the dust that blanketed the area. On June 20, 2007, GAO
testified on the Environmental Protection Agency's (EPA) second program
to address indoor contamination. See, GAO, World Trade Center:
Preliminary Observations on EPA's Second Program to Address Indoor
Contamination, GAO-07-806T (Washington, D.C.: June 20, 2007).
[17] There is not a definitive count of the number of people who served
as responders. Estimates have ranged from about 40,000 to about 91,000.
[18] The responders included firefighters, law enforcement officers,
emergency medical technicians and paramedics, morticians, health care
professionals, construction workers, iron workers, heavy equipment
operators, mechanics, engineers, truck drivers, carpenters,
telecommunications workers, and day laborers.
[19] See, for example, Centers for Disease Control and Prevention,
"Mental Health Status of World Trade Center Rescue and Recovery Workers
and Volunteers--New York City, July 2002-August 2004," Morbidity and
Mortality Weekly Report, vol. 53 (2004); "Physical Health Status of
World Trade Center Rescue and Recovery Workers and Volunteers--New York
City, July 2002-August 2004," Morbidity and Mortality Weekly Report,
vol. 53 (2004); and "Surveillance for World Trade Center Disaster
Health Effects among Survivors of Collapsed and Damaged Buildings,"
Morbidity and Mortality Weekly Report, vol. 55 (2006). See also G. I.
Banauch et al., "Pulmonary Function after Exposure to the World Trade
Center in the New York City Fire Department," American Journal of
Respiratory and Critical Care Medicine, vol. 174, no. 3 (2006).
[20] Banauch et al., "Pulmonary Function."
[21] R. Herbert et al., "The World Trade Center Disaster and the Health
of Workers: Five-Year Assessment of a Unique Medical Screening
Program," Environmental Health Perspectives, vol. 114, no. 12 (2006).
[22] R. Gross et al., "Posttraumatic Stress Disorder and Other
Psychological Sequelae Among World Trade Center Clean Up and Recovery
Workers," Annals of the New York Academy of Sciences, vol. 1071 (2006).
[23] G. Izbicki et al, "World Trade Center 'Sarcoid Like' Granulomatous
Pulmonary Disease in New York City Fire Department Rescue Workers,"
Chest, vol. 131 (2007).
[24] In addition to these programs, a New York State responder
screening program received federal funding for screening New York State
employees and National Guard personnel who responded to the WTC attack
in an official capacity. This program ended its screening examinations
in November 2003.
[25] The NY/NJ WTC Consortium consists of five clinical centers
operated by (1) Mount Sinai-Irving J. Selikoff Center for Occupational
and Environmental Medicine; (2) Long Island Occupational and
Environmental Health Center at SUNY, Stony Brook; (3) New York
University School of Medicine/Bellevue Hospital Center; (4) Center for
the Biology of Natural Systems, at CUNY, Queens College; and (5)
University of Medicine and Dentistry of New Jersey Robert Wood Johnson
Medical School, Environmental and Occupational Health Sciences
Institute. Mount Sinai's clinical center, which is the largest of the
five centers, also receives federal funding to operate a data and
coordination center to coordinate the work of the five clinical centers
and conduct outreach and education, quality assurance, and data
management for the NY/NJ WTC Consortium.
[26] Project COPE and the POPPA program operate independently of the
NYPD.
[27] The WTC Health Registry also provides information on where
participants can seek health care.
[28] FEMA is the agency responsible for coordinating federal disaster
response efforts under the National Response Plan.
[29] See Consolidated Appropriations Resolution, 2003, Pub. L. No. 108-
7, 117 Stat. 11, 517; 2002 Supplemental Appropriations Act for Further
Recovery from and Response to Terrorist Attacks on the United States,
Pub. L. No. 107-206, 116 Stat. 820, 894; Department of Defense and
Emergency Supplemental Appropriations for Recovery from and Response to
Terrorist Attacks on the United States Act, 2002, Pub. L. No. 107-117,
115 Stat. 2230, 2338; and 2001 Emergency Supplemental Appropriations
Act for Recovery from and Response to Terrorist Attacks on the United
States, Pub. L. No. 107-38, 115 Stat. 220-221.
[30] Pub. L. No. 108-7, 117 Stat. 517.
[31] The statute required CDC, in expending such funds, to give first
priority to specified existing programs that administer baseline and
follow-up screening; clinical examinations; or long-term medical health
monitoring, analysis, or treatment for emergency services personnel or
rescue and recovery personnel. It required CDC to give secondary
priority to similar programs coordinated by other entities working with
the State of New York and New York City. Pub. L. No. 109-148, §5011(b),
119 Stat. 2814.
[32] U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq
Accountability Appropriations Act, 2007, Pub. L. No. 110-28, ch. 5, 121
Stat. 112, 166 (2007).
[33] The program previously suspended examinations from March 2004 to
December 2005. See GAO-06-481T.
[34] The agreement was a modification of ASPR's February 2006
interagency agreement with NIOSH that covers screenings for former
federal employees.
[35] Before an agreement between NIOSH and FOH could be signed, the
agreement between ASPR and NIOSH required several technical
corrections. The revised ASPR-NIOSH agreement extended the availability
of funding for the WTC Federal Responder Screening Program to April 30,
2008.
[36] These services are for diagnostic purposes only. FOH does not
initiate or pay for treatment.
[37] Federal responders can currently obtain monitoring through the
periodic surveys of the WTC Health Registry.
[38] Around that time, NIOSH was providing screening services for
nonfederal responders in the NYC metropolitan area through the NY/NJ
WTC Consortium and FDNY's WTC program. Nonfederal responders residing
outside the NYC metropolitan area were able to travel at their own
expense to the NYC metropolitan area to obtain screening services
through the NY/NJ WTC Consortium.
[39] According to the NYC Department of Health and Mental Hygiene,
about 7,000 nonfederal and federal responders residing outside the NYC
metropolitan area have enrolled in the WTC Health Registry.
[40] According to a NIOSH official, AOEC's application did not
adequately address how to coordinate and implement a monitoring program
with complex data collection and reporting requirements. In addition,
NIOSH officials identified other reasons the application was rejected
by reviewers, including the fact that the application lacked an overall
statement of programmatic goals or specific aims, the administrative
and clinical evaluation plans described in the application were too
vague, and the proposed leadership for the program did not include
trained mental health professionals.
[41] DCC received this amount as a part of its award continuation for
DCC's second year of funding. DCC's second year award continuation
totaled about $3,778,000 and was for its role as coordinator for the
NY/NJ WTC Consortium. The award continuation was used to pay for all
data management, data analysis, and program coordination activities
performed from June 2005 through May 2006.
[42] DCC received this amount as a part of its award continuation for
DCC's third year of funding. DCC's third year award continuation
totaled about $3,924,000 and was for its role as coordinator for the
NY/NJ WTC Consortium. The award continuation was used to pay for all
data management, data analysis, and program coordination activities
performed from June 2006 through May 2007.
[43] Contracts were originally established with 11 clinics in 8 states,
but 1 clinic discontinued its participation in the program after
conducting one examination. The 10 active clinics are located in
Arkansas, California, Illinois, Maryland, Massachusetts, New York, and
Ohio. Of the 10 active clinics, 7 are AOEC member clinics.
[44] Institutional review boards are groups that have been formally
designated to review and monitor biomedical research involving human
subjects, such as research based on data collected from screening and
monitoring examinations.
[45] According to NIOSH and DCC officials, efforts to provide
monitoring services to federal responders residing outside the NYC
metropolitan area may be included in the national program.
[46] A NIOSH official told us that an AOEC network of 50 member clinics
would not be sufficient by itself to provide the three services to
nonfederal responders nationwide.
[47] Department of Health and Human Services, Sources Sought Notice:
National Medical Monitoring and Treatment Program for World Trade
Center (WTC) Rescue, Recovery, and Restoration Responders and
Volunteers, SSA-WTC-001 (Mar. 15, 2007).
[48] QTC is a private provider of government-outsourced occupational
health and disability examination services.
[49] As of June 2007, DCC identified 1,151 nonfederal responders
residing outside the NYC metropolitan area who requested screening and
monitoring services but were too ill or lacked financial resources to
travel to NYC or any of DCC's 10 contracted clinics.
[50] In addition to this award, according to a NIOSH official, NIOSH
approved DCC's request to use the funds remaining from the June 2005
award, about $389,000, to provide screening and monitoring services to
nonfederal responders residing outside the NYC metropolitan area.
Therefore, as of June 2007, a total of $1,189,600 is available for this
purpose. In addition, when NIOSH receives DCC's financial status report
in summer 2007, it will decide if any unused funds from the June 2006
award will be made available to DCC for providing these services.
[51] Some nonfederal responders residing outside the NYC metropolitan
area may have access to privately funded treatment services. In June
2005 the American Red Cross funded AOEC to provide treatment services
for these responders. As of June 2007, AOEC had contracted with 40 of
its member clinics located in 27 states and the District of Columbia to
provide these services. The initial grant from the American Red Cross
will be expended by June 30, 2007, but American Red Cross officials
told us that funding may be provided into 2008.
[52] Federal responders are not eligible for services through these
four programs.
[53] In addition to funding from NIOSH, the FDNY WTC program and NY/NJ
WTC Consortium received funding in 2006 from the American Red Cross to
provide treatment services. Officials from the American Red Cross
expected that the funds it provided would be expended by June 30, 2007,
except for the Mount Sinai Clinical Center's funding, which is expected
to be expended by July 31, 2007. American Red Cross officials told us
that their organization is ending its support of the two health
programs and does not plan to renew treatment funding.
[54] Of the $24 million remaining from the $75 million appropriation to
CDC, NIOSH used about $15 million to support monitoring and other WTC-
related health services conducted by the FDNY WTC program and NY/NJ WTC
Consortium. ATSDR awarded $9 million to the WTC Health Registry to
continue its collection of health data.
[55] Pulmonary fibrosis is a condition characterized by the formation
of scar tissue in the lungs following the inflammation of lung tissue.
[56] The NY/NJ WTC Consortium now offers treatment services at no cost
to responders; however, prior to fall 2006 the program attempted when
possible to obtain reimbursement for its services from health insurance
carriers and to obtain applicable co-payments from responders.
[57] Associated program costs include expenses for data analysis and
program administration.
[58] The estimate also did not include the cost of providing baseline
medical screenings.
[59] NIOSH and its grantees estimated that monitoring and treatment
costs could be about $230 million annually if 75 percent of the
responders projected to need medical treatment in a given year received
such services and that these costs could be about $283 million annually
if 100 percent of the responders projected to need medical treatment in
a given year received such services. To estimate the annual cost of
monitoring, NIOSH and its grantees estimated that the cost of examining
a responder not receiving medical treatment from a WTC health program
would be $1,500 and the cost for a responder receiving treatment would
be $500. (NIOSH officials explained that the cost of conducting a
monitoring examination is lower for a responder who is receiving care
on a regular basis because some diagnostic procedures needed for
monitoring will have already been performed.) The January 2007 estimate
projected that annual monitoring costs would account for about $35.7
million of its $230 million estimate and for about $30.7 million of its
$283 million estimate.
[60] NIOSH and its grantees used New York State workers' compensation
reimbursement rates.
[61] Treatment utilization is the volume or complexity of care provided
to patients based on their medical needs.
[62] NIOSH and its grantees assumed that other providers' treatment
costs would be equivalent to those of the NY/NJ WTC Consortium.
[63] Indirect costs are for functions that indirectly support a
program, such as administrative activities, utilities, and building
maintenance.
[64] The WTC medical monitoring protocol calls for an in-office
assessment of a responder's physical and mental health every 18 months;
the estimate assumes that these visits occur every 12 months. NIOSH
officials told us that they assumed a 12-month interval because that is
what clinicians prefer for optimal identification and treatment of
illnesses.
[65] In an effort separate from the estimation effort of NIOSH and its
grantees, an NYC mayoral panel that reviewed WTC health effects issued
a report in February 2007 that contained an estimate of the cost to
provide medical services through the FDNY WTC and the NY/NJ WTC
Consortium programs. This effort resulted in a lower estimate of the
cost of providing medical services through these two programs--
approximately $107 million in fiscal year 2008. The NYC effort was
affected by some of the same factors that limited the reliability of
the estimate of NIOSH and the grantees, such as the lack of actual
treatment cost data. See World Trade Center Health Panel, Addressing
the Health Impacts of 9-11: Report and Recommendations to Mayor Michael
R. Bloomberg.
[66] These data were not available when NIOSH and its grantees made
their estimate of WTC costs in January 2007.
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site (www.gao.gov). Each weekday, GAO posts
newly released reports, testimony, and correspondence on its Web site.
To have GAO e-mail you a list of newly posted products every afternoon,
go to www.gao.gov and select "Subscribe to Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office 441 G Street NW, Room LM
Washington, D.C. 20548:
To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 U.S.
Government Accountability Office, 441 G Street NW, Room 7125
Washington, D.C. 20548:
Public Affairs:
Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, D.C. 20548:
