World Trade Center Health Program
Potential Effects of Implementation Options Gao ID: GAO-11-735R August 4, 2011In Process
Creating a consolidated data center could lead to cost savings and enhanced research opportunities; however, consolidation could require upfront expenditures. In addition, establishing a consolidated data center could result in a loss of responders' clinical data from the WTCHP because of the potential need to have responders sign new consent forms to enable use of their data for research. Responders provided consent to their respective clinical centers to send their clinical data to the center's DCC for research purposes, and existing consent might not authorize the use of such data by a consolidated data center. Responders might be unavailable or unwilling to provide consent again. Although most WTC responders outside the NYC area live near a VA facility, the use of VA facilities for the WTCHP could affect access to health services for WTC responders because not all types of clinical expertise are available at all VA facilities, VA facilities do not always have space available to serve nonveterans, and it would take an undetermined length of time to implement an agreement between VA and HHS. The use of VA facilities for the WTCHP could also affect enrollment retention because WTC responders might need to change health care providers. Providing prescription drugs to WTC responders through an existing federal prescription drug purchasing program could reduce drug prices. It might also affect the availability of options for filling prescriptions and responders' access to certain prescription drugs. In addition, VA and DOD officials told us that use of their respective drug purchasing programs for WTC responders would require administrative changes to their programs. In written comments, DOD concurred with a draft of this report. HHS and VA provided technical comments, which we incorporated as appropriate.
GAO-11-735R, World Trade Center Health Program: Potential Effects of Implementation Options
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GAO-11-735R:
United States Government Accountability Office:
Washington, DC 20548:
August 4, 2011:
The Honorable Tom Harkin:
Chairman:
The Honorable Michael B. Enzi:
Ranking Member:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
The Honorable Fred Upton:
Chairman:
The Honorable Henry A. Waxman:
Ranking Member:
Committee on Energy and Commerce:
United States House of Representatives:
Subject: World Trade Center Health Program: Potential Effects of
Implementation Options:
The James Zadroga 9/11 Health and Compensation Act of 2010 became law
on January 2, 2011, and established a World Trade Center Health
Program (WTCHP) to assume the functions of the World Trade Center
(WTC) responder health programs beginning on July 1, 2011.[Footnote
1], Footnote 2] From September 11, 2001, through fiscal year 2010,
approximately $475 million in federal funds was made available for
screening, monitoring, and treating WTC responders for illnesses and
conditions related to the WTC disaster.[Footnote 3],[Footnote 4] These
include asthma, persistent coughing, and other respiratory conditions
and mental health conditions such as depression, anxiety, and post-
traumatic stress disorder (PTSD). The three federal programs that
provided screening, monitoring, and treatment services to responders
prior to July 1, 2011, which we refer to here as the WTC responder
health programs, were the New York City Fire Department's (FDNY) WTC
Medical Monitoring and Treatment Program, the New York/New Jersey (NY/
NJ) WTC Consortium,[Footnote 5] and the WTC National Responder Health
Program. The FDNY WTC program and the NY/NJ WTC Consortium provided
services to WTC responders in the New York City (NYC) metropolitan
area and each had a Data and Coordination Center (DCC) that was
responsible for, among other things, collecting and analyzing clinical
data for research on WTC-related health conditions. The WTC National
Responder Health Program provided services to WTC responders outside
the NYC area and did not have a DCC. The federal agency that was
responsible for oversight of the three WTC responder health programs
was the Centers for Disease Control and Prevention's (CDC) National
Institute for Occupational Safety and Health (NIOSH) in the Department
of Health and Human Services (HHS). According to NIOSH, as of March
31, 2011, the WTC responder health programs had identified about
55,000 WTC responders who were eligible for health services.
The WTCHP is administered by HHS and provides screening, monitoring,
and treatment services through contracted clinical centers in the NYC
area for responders in that area and through a nationwide network of
providers for responders outside the NYC area. In addition to these
health services, the WTCHP is required to establish a program to pay
for prescription drugs prescribed under the program and to contract
with one or more data centers to coordinate patient outreach and, by
analyzing claims data, conduct research on WTC-related health
conditions. Although the Zadroga Act generally provides that the WTCHP
is the primary payer for benefits for responders under the WTCHP, the
act establishes the WTCHP as a secondary payer in certain
circumstances.[Footnote 6] In May 2011, HHS delegated authority to the
Centers for Medicare & Medicaid Services to provide payment services
for the WTCHP. All other WTCHP activities will be administered by
NIOSH. In April 2011, NIOSH issued a solicitation for clinical centers
to provide health services to responders and a solicitation for one or
more data centers to provide case management and increased capacity
for analysis of responder health conditions; on July 1, 2011, NIOSH
awarded contracts to six clinical centers and two data centers.
[Footnote 7] The Zadroga Act established the WTCHP Fund and provided
appropriations for the federal share of expenditures for each of
fiscal years 2012 through 2016, as well as the last calendar quarter
of fiscal year 2011, totaling a maximum of $1.6 billion.[Footnote 8]
The Zadroga Act requires us to study feasibility, efficiency, and
effectiveness issues related to the WTCHP established by the act,
including the WTCHP's potential use of one consolidated data center
rather than multiple data centers, the potential use of Department of
Veterans Affairs (VA) health care facilities to serve WTC responders
outside the NYC area, and the potential use of an existing federal
prescription drug purchasing program to provide prescription drugs for
all WTC responders.[Footnote 9] The act expressly authorizes (but does
not require) the WTCHP to enter into an agreement with VA to provide
WTCHP services to responders living outside the NYC area through VA
facilities. However, the act does not expressly authorize an agreement
with a federal prescription drug purchasing program to provide
prescription drugs to WTC responders. In this report, we identify
potential effects of (1) creating a consolidated data center for the
WTCHP, (2) using VA facilities to provide WTCHP services to responders
living outside the NYC area, and (3) using an existing federal
prescription drug purchasing program for the WTCHP.
To identify potential effects of creating a consolidated data center
for the WTCHP, we interviewed DCC, NIOSH, and WTC Steering Committee
officials who were involved with managing or overseeing the DCCs.
[Footnote 10] To obtain additional information about the two DCCs and
the potential effects of consolidation, we also reviewed documents
related to the DCCs, including progress reports and clinical
instruments used for data collection, relevant provisions of the
Zadroga Act, our prior reports, and documents describing initiatives
for consolidating federal data centers.
To identify potential effects of using VA facilities to provide WTCHP
services to responders living outside the NYC area, we interviewed
officials involved in implementing or overseeing the WTC National
Responder Health Program, including officials from Logistics Health,
Incorporated (LHI), the contractor that has been responsible for
implementing the program.[Footnote 11] We also interviewed VA
officials knowledgeable about the provision of health services for
individuals served by VA. We reviewed relevant documents related to
WTC National Responder Health Program operations and to the provision
of VA health services, such as VA directives.
In addition, we calculated the percentages of WTC responders living
outside the NYC area who resided within certain designated distances
of a VA facility by analyzing ZIP code data on the locations of WTC
responders' residences and the locations of relevant VA facilities,
including VA medical centers (VAMC), community-based outpatient
clinics (CBOC), and independent outpatient clinics (IOC).[Footnote 12]
The data for WTC responders' residential locations were provided by
the NY/NJ WTC Consortium DCC, the entity that managed recruitment for
the WTC National Responder Health Program. According to the DCC's
database, as of March 19, 2011, 4,621 of the approximately 53,000 WTC
responders are known to reside outside the NYC area, including in
locations outside the country. The data for the locations of VA
facilities were provided by VA and included ZIP codes for 150 VAMCs,
739 CBOCs, and 5 IOCs in the United States. Our analysis has several
limitations. First, there was no way to determine whether the VA
facilities in the ZIP codes nearest the responders' ZIP codes would
have the appropriate expertise or space available to provide services
in the future. Second, the analysis does not account for the precise
residential location of a responder in a ZIP code; distances were
calculated from the geographic center of a ZIP code in which a
responder resides to the geographic center of a ZIP code in which a VA
facility is located.[Footnote 13] Finally, the accuracy of the ZIP
code data was not verified. We assessed the reliability of the ZIP
code level data by interviewing knowledgeable DCC and VA officials,
and we determined that the data were sufficiently reliable for our
purposes.
To identify potential effects of using an existing federal
prescription drug purchasing program for the WTCHP, we interviewed
officials from the WTC responder health programs and NIOSH who were
involved in implementing or overseeing the programs' seven
prescription drug plans.[Footnote 14] We limited our scope to the
following federal prescription drug purchasing programs: VA's drug
purchasing program; TRICARE, the Department of Defense's (DOD) health
care program; and HHS's 340B Drug Pricing Program.[Footnote 15],
[Footnote 16] We interviewed officials from VA; DOD; and HHS's Health
Resources and Services Administration (HRSA), which administers the
340B Drug Pricing Program. We reviewed documents related to the WTC
responder health programs' prescription drug plans and the federal
drug purchasing programs, including drug plan information provided to
beneficiaries and drug formularies.[Footnote 17] In addition, we
obtained from each of the WTC prescription drug plans the names of the
10 prescription drugs most frequently used by WTC responders covered
by each plan in 2010. The top 10 lists for the seven plans yielded a
total of 29 prescription drugs. We then determined which of the 29
drugs were on the formularies used by VA and TRICARE and were
available through the 340B program.[Footnote 18]
We conducted this performance audit from March 2011 to August 2011, in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
Results in Brief:
Creating a consolidated data center could lead to cost savings and
enhanced research opportunities; however, consolidation could require
upfront expenditures. In addition, establishing a consolidated data
center could result in a loss of responders' clinical data from the
WTCHP because of the potential need to have responders sign new
consent forms to enable use of their data for research. Responders
provided consent to their respective clinical centers to send their
clinical data to the center's DCC for research purposes, and existing
consent might not authorize the use of such data by a consolidated
data center. Responders might be unavailable or unwilling to provide
consent again. Although most WTC responders outside the NYC area live
near a VA facility, the use of VA facilities for the WTCHP could
affect access to health services for WTC responders because not all
types of clinical expertise are available at all VA facilities, VA
facilities do not always have space available to serve nonveterans,
and it would take an undetermined length of time to implement an
agreement between VA and HHS. The use of VA facilities for the WTCHP
could also affect enrollment retention because WTC responders might
need to change health care providers. Providing prescription drugs to
WTC responders through an existing federal prescription drug
purchasing program could reduce drug prices. It might also affect the
availability of options for filling prescriptions and responders'
access to certain prescription drugs. In addition, VA and DOD
officials told us that use of their respective drug purchasing
programs for WTC responders would require administrative changes to
their programs. In written comments, DOD concurred with a draft of
this report. HHS and VA provided technical comments, which we
incorporated as appropriate.
Background:
Within HHS, NIOSH awarded funds to and oversaw the WTC responder
health programs. Beginning in 2001, the FDNY WTC program and the NY/NJ
WTC Consortium received federal funding to provide services to
responders. The programs began as screening and monitoring programs,
tracking the health status of WTC responders. In December 2005, the
Congress first appropriated funds specifically for treatment programs
for certain responders with health conditions related to the WTC
disaster,[Footnote 19] and in fall 2006 NIOSH began awarding funds for
outpatient and inpatient treatment. NIOSH contracted with LHI in 2008
to implement the WTC National Responder Health Program.[Footnote 20]
According to NIOSH, of the almost 55,000 eligible responders, about
49,000 had been screened as of March 31, 2011, by the three WTC
responder health programs;[Footnote 21] from April 1, 2010, to March
31, 2011, about 27,000 were monitored and about 16,000 were treated.
[Footnote 22]
DCCs:
In 2004, NIOSH entered into cooperative agreements with two DCCs to
provide data management and coordination for the two largest WTC
responder health programs, which are located in the NYC area. The FDNY
Bureau of Health Services operated the DCC for the FDNY WTC program,
and the Mount Sinai School of Medicine operated the DCC for the NY/NJ
WTC Consortium.[Footnote 23] According to NIOSH's original request for
applications in 2003, the two DCCs were to be responsible for
monitoring the quality and quantity of data received from their
respective clinical centers, maintaining an electronic clinical data
entry tool, analyzing clinical data, providing reports to NIOSH, and
coordinating outreach and patient follow-up. The FDNY DCC provided
services to active duty FDNY firefighters, emergency medical services
personnel, civilian volunteers, and retired nonactive duty FDNY
firefighters; the Consortium DCC provided services to a more
heterogeneous group of WTC responders, including police officers,
sanitation workers, construction workers, transit workers, a wide
range of volunteers, and active duty and retired firefighters who
responded from locations outside the NYC area. The cooperative
agreements between NIOSH and the DCCs ended on June 30, 2011.
Under the Zadroga Act, the WTCHP is required to contract with one or
more data centers to collaborate with the clinical centers that will
be providing services to WTC responders in the NYC metropolitan area,
[Footnote 24] and on July 1, 2011, NIOSH awarded contracts to two data
centers; the two data centers are the same entities that served as the
DCCs for the FDNY WTC program and the NY/NJ WTC Consortium. The WTCHP
data centers will continue the activities of the WTC responder health
programs' DCCs in addition to new activities. The responsibilities for
each WTCHP data center include analyzing and reporting on claims data;
coordinating with corresponding clinical centers to obtain input on
the analysis and reporting of data collected; developing protocols for
screening, monitoring, and treatment; coordinating outreach
activities; and establishing criteria for the credentialing of medical
providers.
We have previously reported on the data collection efforts of WTC
responder health programs[Footnote 25] and on federal data centers in
general, including the opportunity to increase government efficiency
through consolidating such centers.[Footnote 26] In February 2010, the
Office of Management and Budget launched the Federal Data Center
Consolidation Initiative (FDCCI) to increase government efficiency.
[Footnote 27] The FDCCI is a governmentwide effort to consolidate more
than 2,000 federal government data centers. We have identified
challenges or potential effects of consolidation in ongoing reviews of
this initiative.[Footnote 28]
Health Care Services for WTC Responders Residing outside the NYC Area:
Since June 2008, NIOSH has contracted with LHI to provide screening,
monitoring, and treatment services to WTC responders who live outside
the NYC metropolitan area.[Footnote 29] Although the WTC National
Responder Health Program did not have a DCC and does not have a data
center, LHI is responsible for tracking and reporting responder
information based on claims data. LHI has been providing monitoring
services to WTC responders through its national network of providers,
and LHI subcontracts with United Medical Resources (UMR) to provide
responders with access to treatment services through
UnitedHealthcare's provider network.[Footnote 30] The base year of the
current contract between NIOSH and LHI ends on September 29, 2011, and
the contract allows for NIOSH to exercise an option to renew the
contract for each of the following four fiscal years. See figure 1 for
a map of residential locations of WTC responders residing outside the
NYC area.
Figure 1: World Trade Center (WTC) Responders Residing outside the New
York City (NYC) Metropolitan Area, by County and by State (as of March
19, 2011):
[Refer to PDF for image: illustrated U.S. map]
Alabama: 34;
Alaska: 26;
Arizona: 93;
Arkansas: 21;
California: 331;
Colorado: 90;
Connecticut: 53;
Delaware: 13;
District of Columbia: 25;
Florida: 711;
Georgia: 121;
Hawaii: 10;
Idaho: 8;
Illinois: 129;
Indiana: 56;
Iowa: 13;
Kansas: 20;
Kentucky: 26;
Louisiana: 20;
Maine: 19;
Maryland: 109;
Massachusetts: 14;
Michigan: 48;
Minnesota: 31;
Mississippi: 14;
Missouri: 43;
Montana: 8;
Nebraska: 26;
Nevada: 45;
New Hampshire: 19;
New Jersey: 43;
New Mexico: 38;
New York: 723;
North Carolina: 194;
North Dakota: 8;
Ohio: 14;
Oklahoma: 16;
Oregon: 48;
Pennsylvania: 205;
Rhode Island: 38;
South Carolina: 80;
South Dakota: 6;
Tennessee: 42;
Texas: 138;
Utah: 36;
Vermont: 9;
Virginia: 164;
Washington: 77;
West Virginia: 19;
Wisconsin: 34;
Wyoming: 4.
Source: GAO analysis of data provided by the New York/New Jersey
(NY/NJ) WTC Consortium‘s data and coordination center (DCC).
Note: The NY/NJ WTC Consortium's DCC, which was operated by the Mount
Sinai School of Medicine, managed recruitment for the WTC National
Responder Health Program. According to its database, 4,621 WTC
responders are known to reside outside the NYC metropolitan area,
including in locations outside the country. As of March 19, 2011, the
DCC's database included ZIP codes and states for 4,368 of the 4,621
WTC responders; ZIP codes and states were not available for 211
responders, and 42 responders reside outside the country or in Guam,
Puerto Rico, or the Virgin Islands. The map represents the locations,
by county, for 4,365 of the responders living outside the NYC
metropolitan area, but within the country; the counties for 3
responders were not available because we could not match the
responders' ZIP codes with counties. The differences in the sizes of
the counties are geographical only and do not reflect the number of
responders in each county.
[End of figure]
The Zadroga Act requires the WTCHP to provide services to WTC
responders outside the NYC area through a national network of
providers, and permits HHS to enter into an agreement with VA to
provide these services in VA facilities.[Footnote 31] The
responsibilities of the WTCHP's national network of providers under
the act will be similar to the responsibilities of the national
network of providers in the WTC National Responder Health Program. In
addition to providing services to veterans, VA provides health
services to certain civilians through its Civilian Health and Medical
Program of the Department of Veterans Affairs (CHAMPVA) program, which
is primarily a fee-for-service program that provides coverage for
certain eligible dependents or survivors of veterans who are
permanently and totally disabled because of a service-connected
disability. Veterans generally have higher priority for services in VA
facilities than do nonveterans;[Footnote 32] CHAMPVA beneficiaries are
eligible to receive health services in most VA facilities, but only on
a space-available basis.
Prescription Drug Plans:
Prior to July 1, 2011, the WTC responder health programs included
seven different prescription drug plans, each of which used program
funds to provide responders with full coverage for prescription
medications listed on a formulary. The seven plans were associated
with the FDNY WTC program, the five clinical centers in the NY/NJ WTC
Consortium, and the WTC National Responder Health Program. Generally,
the prescription drug plans independently contracted with a pharmacy
benefit manager (PBM) to purchase and distribute prescription drugs to
its beneficiaries.[Footnote 33] In 2010, the WTC responder health
programs' prescription drug plans filled over 140,000 prescriptions at
a cost of $25.3 million. WTC responders paid no premiums or copayments
for drugs to treat WTC-related health conditions. Depending on the WTC
prescription drug plan, responders could obtain their drugs through a
mail order pharmacy, network retail pharmacy, or in-house pharmacy
located in their clinic.
The Zadroga Act requires the WTCHP to establish a program to pay for
medically necessary outpatient prescription drugs prescribed for WTC-
related health conditions.[Footnote 34] According to a NIOSH official,
starting on July 1, 2011, NIOSH began using a single PBM to administer
the prescription drug benefit for all of the WTCHP responders in the
NYC area. A NIOSH official told us that prescription drugs for WTC
responders residing outside the NYC area will continue to be provided
through the LHI contract in the near term.
The federal government operates several prescription drug purchasing
programs[Footnote 35]--including VA's drug purchasing program, DOD's
TRICARE, and HRSA's 340B Drug Pricing Program--which receive prices
that are typically lower than those otherwise available. VA and
TRICARE provide drug benefits for eligible beneficiaries by purchasing
and distributing prescription drugs. The 340B Drug Pricing Program
gives enrolled entities access to discounted drug prices, called 340B
ceiling prices, and gives them the option to contract with a prime
vendor, which can negotiate discounts with manufacturers at or below
the mandatory 340B ceiling price.
VA's drug purchasing program includes a national formulary to help
standardize veterans' access to medications across the country.
[Footnote 36] The formulary includes drugs that generally must be
prescribed by a VA provider and filled through VA's mail order
pharmacy or at a VA pharmacy. VA pays the lowest of several prices
available for a given drug and can negotiate with suppliers to receive
additional discounts.
DOD's prescription drug benefit is provided to active duty and retired
uniformed service members and their families through TRICARE. In 2005,
DOD implemented a uniform formulary that includes drugs prescribed for
TRICARE beneficiaries by providers at military treatment facilities
and by outside providers. Beneficiaries can obtain their medications
through TRICARE's mail order pharmacy, network retail pharmacies,
nonnetwork retail pharmacies, and military treatment facilities. Like
VA, TRICARE pays the lowest of several prices and can receive
additional discounts through negotiation with suppliers.
HRSA's 340B Drug Pricing Program gives access to discounted drug
prices to enrolled entities that provide services to low-income and
other individuals who experience barriers gaining access to care.
[Footnote 37] The 340B Drug Pricing Program enables enrolled entities
to stretch federal resources so that they can serve additional
eligible patients and provide more comprehensive services. In order to
have their drugs covered by Medicaid, drug manufacturers must agree to
charge entities that participate in the 340B program prices that do
not exceed an amount determined by statutory formula. Enrolled
entities establish their own formularies and may dispense drugs
through in-house pharmacies, contracted retail pharmacies, or both.
[Footnote 38]
Creating a Consolidated Data Center Could Reduce Costs and Enhance
Research, but Would Require Upfront Investment and Might Adversely
Affect Enrollment Retention:
Creating a Consolidated Data Center Has Potential for Cost Savings and
Enhanced Research, but Upfront Investment Would Be Needed:
Creating a consolidated data center could lead to cost savings, such
as by reducing duplicative staff positions for data management and
analysis. The FDNY and Consortium DCCs conducted similar activities
related to the collection and maintenance of data, such as data
monitoring, data cleaning, and the preparation of quality assurance
reports. According to Consortium DCC officials, the DCC monitored, for
example, types and dates of clinical visits by responders and
regularly conducted data cleaning as part of its quality assurance
efforts in generating required reports for NIOSH. FDNY's DCC worked on
similar data-and quality-assurance-related tasks, such as revising
patient questionnaires and data cleaning. In a consolidated data
center, such activities would be conducted by a single entity, which
could result in cost savings due to reduced duplication of effort.
Such savings have been projected for other data center consolidations.
For example, according to the federal interagency Chief Information
Officers Council--which was established to improve agency practices
related to the development and implementation of federal information
resources--the FDCCI would likely lead to cost savings through the
reduction of redundant and duplicative information technology projects
and infrastructure.[Footnote 39]
Using a consolidated data center could also enhance opportunities to
conduct research on health effects by increasing the number of WTC
responders whose information is in the data set and available for
analysis. The FDNY and Consortium DCCs maintained separate data sets
for their respective groups of WTC responders. The single, merged data
set that would result from a consolidated data center could facilitate
enhanced epidemiologic research because this larger data set would
likely allow researchers to perform analyses that would not be
possible with smaller data sets. For example, researchers could more
effectively study conditions that are experienced by WTC responders
less frequently, such as cancer and pulmonary fibrosis, including the
efficacy of treatments for such conditions.
Before cost savings can be realized, however, consolidation could
require upfront expenditures, including investments in information
technology systems. A NIOSH official said there would be upfront costs
associated with merging the FDNY and Consortium DCCs' responder
population data sets. For example, the two DCCs had different
information technology systems for collecting clinical data. Creation
of a consolidated data center could result in the need to invest in
standardizing information technology systems. In our 2011 report on
opportunities to reduce potential duplication in government, we noted
that there are upfront costs associated with data center consolidation
in the FDCCI.[Footnote 40] We also reported that although data center
consolidation could achieve more efficient information technology
operations, upfront funding would be needed for the consolidation
effort long before any cost savings could accrue.[Footnote 41],
[Footnote 42]
Effort to Create a Consolidated Data Center Could Result in a Loss of
Responders and Data from the WTCHP:
Establishing a consolidated data center could create a need for a new
consent process to enable the center to use responders' previously
collected data and collect future data. Responders provided consent to
their respective clinical centers to send their clinical data to the
center's DCC for research purposes, and according to Consortium
officials, existing consent may not authorize the use of such data by
a consolidated data center. For example, Consortium officials told us
that if the clinical centers have to transfer clinical data to a
consolidated data center that is an entity different from the DCC to
which they are already sending data, each responder would have to sign
a new consent form. The officials said that responders might be
unavailable or unwilling to provide consent again. This could lead to
decreased enrollment retention. If retention declines, the WTCHP could
lose access to responder data.[Footnote 43] Such a loss of data could
pose a problem for the WTCHP, because one of the major goals of the
WTCHP is to conduct research on responders to inform the provision of
care for conditions resulting from exposure during the WTC disaster.
In addition to the need for a new consent process, potential
resistance from stakeholder organizations and WTC responders,
resulting in part from long-standing professional loyalties, could
affect the success of a consolidated data center. We previously
reported that a potential challenge to creating a consolidated data
center is overcoming cultural resistance to major organizational
change.[Footnote 44] WTC officials said that the FDNY and Consortium
DCC organizations and responders have unique identities and loyalties.
For example, FDNY DCC officials attributed their high rate of
responder retention to the fact that they maintained an
employer/employee-based WTC program and the FDNY responders identify
closely with the FDNY institution. FDNY DCC officials told us that
responders were significantly more willing to accept the program's
outreach through telephone calls the responders knew originated from
the FDNY in comparison with calls where they did not recognize the
caller's telephone number. If NIOSH chooses to use a consolidated data
center, buy-in from stakeholders--including organizations providing
services to WTC responders, unions, and respective groups of
responders--would be critical.
According to DCC officials, the creation of a consolidated data center
could also disrupt the close relationships and bonds of trust that
have been developed over the past decade among the DCCs, the clinical
centers, and their respective groups of responders. The officials
believe these bonds are important for outreach and retention. As part
of their scope of activities, the DCCs were involved in the programs'
outreach efforts, either directly or by supporting the efforts of the
clinical centers. For example, the Consortium DCC employed several
outreach strategies targeting responders, including issuing quarterly
newsletters, sending e-mails with relevant stories from the press,
organizing conferences, and translating materials into multiple
languages. Consortium DCC officials told us that nothing replaced the
value of a responder having face-to-face contact with a familiar
institution and that one of the Consortium DCC's key outreach
strategies was to have staff in the community maintain direct contact
with responders. DCC officials observed that for a consolidated data
center to be successful in maintaining responder retention, it would
have to establish strong relationships with the clinical centers and
responders.
Using VA Facilities to Provide WTCHP Services outside NYC Area Could
Affect Access and Enrollment Retention:
Most WTC Responders outside NYC Area Live Near a VA Facility:
Most WTC responders outside the NYC area live near a VA facility.
About 61 percent of the WTC responders outside the NYC area (2,665 of
the 4,368 in the NY/NJ WTC Consortium DCC database)[Footnote 45]
reside less than 30 miles from a VAMC, and about 90 percent (3,947 of
the 4,368) reside less than 30 miles from a CBOC.[Footnote 46] Figure
2 shows the percentages of responders outside the NYC area living
within certain designated distances of VAMCs and CBOCs.
Figure 2: Percentages of the World Trade Center (WTC) Responders
outside the New York City (NYC) Area Living within Designated
Distances of Department of Veterans Affairs (VA) Medical Facilities:
[Refer to PDF for image: vertical bar graph]
Distance (miles): 0-14;
VA medical center: 36%;
VA community-based outpatient clinic: 65%.
Distance (miles): 15-29;
VA medical center: 25%;
VA community-based outpatient clinic: 25%.
Distance (miles): 30-44;
VA medical center: 14%;
VA community-based outpatient clinic: 6%.
Distance (miles): 45-59;
VA medical center: 8%;
VA community-based outpatient clinic: 2%.
Distance (miles): 60-74;
VA medical center: 5%;
VA community-based outpatient clinic: 1%.
Distance (miles): 75 and over;
VA medical center: 12%;
VA community-based outpatient clinic: 0%.
Source: GAO analysis of data provided by the New York/New Jersey
(NY/NJ) WTC Consortium‘s data and coordination center (DCC)and VA.
Note: The NY/NJ WTC Consortium's DCC, which was operated by the Mount
Sinai School of Medicine, managed recruitment for the WTC National
Responder Health Program. According to its database, 4,621 WTC
responders are known to reside outside of the NYC metropolitan area,
including in locations outside the country. As of March 19, 2011, the
DCC's database included residential locations (including ZIP codes and
states) for 4,368 of those 4,621 WTC responders. As of September 30,
2010, VA's database included 150 VA medical centers and 739 VA
community-based outpatient clinics (CBOC) located in the United
States, as well as the locations for 5 VA independent outpatient
clinics (IOC) also located in the United States. For this analysis, we
included the IOCs with the CBOCs. Percentages in figure for CBOCs do
not add to 100 due to rounding.
[End of figure]
Using VA Facilities for WTCHP Could Affect Access:
Use of VAMCs and CBOCs for the WTCHP could affect access to health
services for WTC responders--whether veterans or nonveterans--because
not all types of clinical expertise are available at all VA
facilities. According to VA officials, many VA providers have
treatment expertise in disorders that may be experienced by
responders, such as pulmonary diseases and PTSD, but certain
specialists are less frequently employed by CBOCs. For example, all
VAMCs provide PTSD specialty care on site, but CBOCs are less likely
to provide these services on site. VA officials told us that it may be
possible for responders who do not live near a VA facility with on-
site PTSD specialty care to use telehealth services.[Footnote 47]
VA facilities do not always have space available to serve nonveterans,
so using these facilities for the WTCHP could have an effect on access
for those WTC responders who are not veterans. VA officials told us
that each VAMC periodically (at least annually) assesses whether it,
or its associated CBOCs, has space available to provide any health
services to nonveterans. VAMCs conduct periodic assessments for each
type of health service they provide to veterans, and these assessments
may result in expansions or reductions of health services for
nonveterans in the medical center or in its associated CBOCs. VA
officials told us that it may be possible to establish an agreement
with HHS for the WTCHP's use of VA facilities that would allow WTC
responders to obtain treatment services in all VA facilities,
regardless of the space available to serve nonveterans.
Access to WTCHP services could also be affected by the length of time
needed to take the administrative actions necessary to implement an
agreement between VA and HHS. VA officials told us that the length of
time needed would depend on the extent of administrative action--such
as developing a process for WTCHP to reimburse VA for services it
provides or for hiring new staff--that would be needed.
Responders' Need to Change Providers Could Affect Enrollment Retention:
The use of VA facilities for the WTCHP could affect enrollment
retention. WTC responders living outside the NYC area would have to
switch from providers in the LHI and UnitedHealthcare networks to
providers in VA facilities.[Footnote 48] NIOSH officials expressed
concern that some responders might choose to no longer participate in
the WTCHP because of a reluctance to discontinue seeing providers with
whom they have an established relationship. Officials said they were
especially concerned about mental health care because developing an
effective relationship between a patient and a mental health provider
can be a sensitive process.
Providing Prescription Drugs to WTC Responders through an Existing
Federal Prescription Drug Purchasing Program Could Reduce Drug Prices,
but Might Affect Access:
Use of an Existing Federal Prescription Drug Purchasing Program Could
Result in Lower Drug Prices for the WTCHP:
Use of VA's drug purchasing program, TRICARE, or the 340B program
could result in lower prescription drug prices for the WTCHP. Prices
available to VA and TRICARE and through the 340B program are typically
lower than those otherwise available. For example, VA and DOD, along
with the Public Health Service and the U.S. Coast Guard, have access
to federal ceiling prices, also called Big Four prices, which are
based on calculations prescribed by statute and generally are at least
24 percent lower than nonfederal average manufacturer prices.[Footnote
49] According to HRSA's Web site, participation in the 340B program
results in significant savings --estimated to be 20 percent to 50
percent--on the cost of outpatient prescription drugs for enrolled
entities. None of the seven WTC prescription drug plans that existed
before July 1, 2011, received the special prescription drug prices
available to these programs, and a NIOSH official told us NIOSH has
not investigated participation in federal purchasing programs in
detail, but expects to do so during the course of the program's first
year of operation.[Footnote 50] VA officials were uncertain whether
legal authority exists to extend the lower pricing available to VA to
the WTCHP if it used VA's program to provide prescription drugs to
responders. In addition, VA officials told us that, in the past, drug
manufacturers challenged an attempt by another federal agency to
extend VA's negotiated prices to nonveteran populations. DOD officials
said that current authority would not allow DOD to obtain lower
pricing for prescription drugs provided to WTC responders at retail
pharmacies. DOD officials were unsure whether legal authority exists
to extend the lower pricing to the WTCHP for prescription drugs
provided through DOD's mail order pharmacy. According to a HRSA
official, legislation would be needed to provide authority for the
WTCHP to become eligible to participate in the 340B program.
Use of an Existing Federal Prescription Drug Purchasing Program Might
Change Responders' Options for Filling Prescriptions:
Options for filling prescriptions varied among the WTC prescription
drug plans that were in place before July 1, 2011, and included mail
order, network retail pharmacy, and in-house pharmacy. In 2010, four
of the plans offered responders more than one option for filling
prescriptions. (See table 1 for the options in 2010 for filling
prescriptions.) According to a NIOSH official, the WTCHP will provide
all WTC responders in the NYC area with at least two options for
obtaining their medications--mail order and retail pharmacies.
[Footnote 51]
Table 1: Options for Filling Prescriptions under Each of the WTC
Prescription Drug Plans, in 2010:
WTC prescription drug plan: Center for the Biology of Natural Systems
at CUNY, Queens College[A];
Options for filling prescriptions: Mail order pharmacy: [Empty];
Options for filling prescriptions: Network retail pharmacy: [Check];
Options for filling prescriptions: In-house pharmacy: [Empty].
WTC prescription drug plan: Long Island Occupational and Environmental
Health Center at SUNY, Stony Brook[A];
Options for filling prescriptions: Mail order pharmacy: [Check];
Options for filling prescriptions: Network retail pharmacy: [Empty];
Options for filling prescriptions: In-house pharmacy: [Empty].
WTC prescription drug plan: Mount Sinai School of Medicine[A];
Options for filling prescriptions: Mail order pharmacy: [Check];
Options for filling prescriptions: Network retail pharmacy: [Check];
Options for filling prescriptions: In-house pharmacy: [Empty].
WTC prescription drug plan: New York City Fire Department's (FDNY) WTC
Medical Monitoring and Treatment Program;
Options for filling prescriptions: Mail order pharmacy: [Check];
Options for filling prescriptions: Network retail pharmacy: [Check];
Options for filling prescriptions: In-house pharmacy: [Empty].
WTC prescription drug plan: New York University School of Medicine/
Bellevue Hospital Center[A];
Options for filling prescriptions: Mail order pharmacy: [Check];
Options for filling prescriptions: Network retail pharmacy: [Empty];
Options for filling prescriptions: In-house pharmacy: [Check].
WTC prescription drug plan: University of Medicine and Dentistry of
New Jersey Robert Wood Johnson Medical School, Environmental and
Occupational Health Sciences Institute[A];
Options for filling prescriptions: Mail order pharmacy: [Empty];
Options for filling prescriptions: Network retail pharmacy: [Check];
Options for filling prescriptions: In-house pharmacy: [Empty].
WTC prescription drug plan: WTC National Responder Health Program;
Options for filling prescriptions: Mail order pharmacy: [Check];
Options for filling prescriptions: Network retail pharmacy: [Check];
Options for filling prescriptions: In-house pharmacy: [Empty].
Source: GAO analysis of information from WTC prescription drug plans.
Note: The seven prescription drug plans in place prior to July 1,
2011, were associated with the three WTC responder health programs.
The New York/New Jersey (NY/NJ) WTC Consortium consisted of five
clinical centers, each of which had its own prescription drug plan.
The other two plans were associated with the FDNY WTC Medical
Monitoring and Treatment Program and the WTC National Responder Health
Program.
[A] A NY/NJ WTC Consortium clinical center.
[End of table]
Options for filling prescriptions vary among the existing federal
prescription drug purchasing programs, and WTCHP's use of any of these
programs might change responders' options for filling prescriptions.
VA beneficiaries may obtain drugs prescribed by VA providers only at a
VA pharmacy or through VA's mail order pharmacy and generally do not
have the option to use retail pharmacies.[Footnote 52] If the WTCHP
used VA's drug purchasing program, some responders would have to
discontinue their use of retail or in-house pharmacies and begin using
mail order or obtain prescriptions at VAMCs or CBOCs. In contrast,
TRICARE currently offers mail order and network and nonnetwork retail
pharmacy options to its beneficiaries, and the 340B Drug Pricing
Program allows for the use of in-house pharmacies and contract retail
and mail order pharmacies. WTCHP's use of either of these programs
would likely expand the number of access options for some responders
in comparison to the options offered by their WTC prescription drug
plans.
Use of an Existing Federal Prescription Drug Purchasing Program Might
Affect Responders' Access to Certain Prescription Drugs:
WTCHP's use of an existing federal prescription drug purchasing
program might affect responders' access to certain prescription drugs.
VA's formulary includes 16 of the 29 prescription drugs most
frequently used by WTC responders in 2010. VA beneficiaries generally
must obtain approval through their providers to obtain nonformulary
drugs.[Footnote 53] According to a VA official, however, it may be
possible to establish an agreement between VA and HHS that would
result in VA providing all prescription drugs on the NIOSH formulary
for WTC responders, regardless of whether the drugs are on VA's
formulary. TRICARE's formulary includes all 29 of the drugs that were
most frequently used by WTC responders in 2010.[Footnote 54]
Responders' access to prescription drugs would not be affected by
WTCHP's enrollment in the 340B program because 340B-enrolled entities
are generally not precluded from purchasing drugs that are not covered
by the 340B program.[Footnote 55] However, purchasing drugs that are
not covered by the 340B program could potentially result in higher
costs to the entity.
WTCHP's Use of VA's Prescription Drug Purchasing Program or TRICARE
Would Require Administrative Changes to Either Program:
VA and DOD officials told us that use of their drug purchasing
programs for WTC responders would result in a need for administrative
changes to their respective programs. VA and DOD officials said that
new administrative procedures would be needed, for example, for
verifying that a responder is eligible for their programs'
prescription benefits. In addition, a VA official said that VA would
need a method for verifying that only prescription drugs that are
covered by the WTCHP prescription drug plan are provided to
responders. Officials were unsure how much time would be required to
implement these and other administrative changes.
Agency Comments:
In written comments, DOD concurred with a draft of this report. HHS
and VA provided technical comments, which we incorporated as
appropriate.
We are sending copies of this report to the Secretaries of HHS,
Defense, and VA. In addition, the report is available at no charge on
GAO's Web site at [hyperlink, http://www.gao.gov]. If you or your
staffs have any questions about this report, please contact me at
(202) 512-7114 or draperd@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 enclosure II.
Signed by:
Debra A. Draper:
Director, Health Care:
Enclosures - 2:
[End of section]
Enclosure I: Abbreviations:
CBOC: community-based outpatient clinics:
CDC: Centers for Disease Control and Prevention:
CHAMPVA: Civilian Health and Medical Program of the Department of
Veterans Affairs:
DCC: Data and Coordination Center:
DOD: Department of Defense:
FDCCI: Federal Data Center Consolidation Initiative:
FDNY: New York City Fire Department:
HHS: Department of Health and Human Services:
HRSA: Health Resources and Services Administration:
IOC: Independent Outpatient Clinic:
LHI: Logistics Health, Incorporated:
NIOSH: National Institute for Occupational Safety and Health:
NYC: New York City NY/NJ New York/New Jersey:
PBM: Pharmacy Benefit Manager:
PTSD: post-traumatic stress disorder:
UMR: United Medical Resources:
VA: Department of Veterans Affairs:
VAMC: VA medical center:
WTC: World Trade Center:
WTCHP: World Trade Center Health Program:
[End of section]
Enclosure II: GAO Contact and Staff Acknowledgments:
GAO Contact:
Debra A. Draper, (202) 512-7114 or draperd@gao.gov:
Acknowledgments:
In addition to the contact named above, Helene F. Toiv, Assistant
Director; Nabajyoti Barkakati; George Bogart; Hernan Bozzolo; Amanda
Cherrin; Anne Hopewell; Mariel Lifshitz; Roseanne Price; and Dan Ries
made key contributions to this report.
[End of section]
Footnotes:
[1] Pub. L. No. 111-347, § 101, 124 Stat. 3623, 3624 (adding title
XXXIII, §§ 3301 et seq., to the Public Health Service Act (PHSA),
codified at 42 U.S.C. §§ 300mm et seq.). In this report, a "responder"
refers to anyone involved in rescue, recovery, or cleanup activities
at or near the vicinity of the WTC or the Staten Island site, the
landfill that was the off-site location of the WTC recovery operation.
Responders include New York City Fire Department (FDNY) personnel;
federal government personnel; and other government and private-sector
workers and volunteers from New York and elsewhere. Other populations
that may receive WTCHP services include community members (referred to
as "survivors") and persons who are not eligible responders or
survivors but who are diagnosed with a WTC-related health condition by
the WTCHP.
[2] For a list of the abbreviations used in this report, see enclosure
I.
[3] See Congressional Research Service, Comparison of the World Trade
Center Medical Monitoring and Treatment Program and the World Trade
Center Health Program Created by Title I of P.L. 111-347, the James
Zadroga 9/11 Health and Compensation Act of 2010, R41292 (Washington
D.C.: Jan. 25, 2011).
[4] In this report, "screening" refers to initial physical and mental
health examinations of responders. "Monitoring" refers to tracking the
health of responders over time through follow-up physical and mental
health examinations.
[5] The NY/NJ WTC Consortium consisted of five clinical centers in the
NY/NJ area. The five clinical centers were operated by (1) Mount Sinai
School of Medicine, (2) Long Island Occupational and Environmental
Health Center at SUNY, Stony Book, (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.
[6] The WTCHP is a secondary payer when a responder has a WTC-related
health condition that is work related and the enrollee has filed an
applicable workers' compensation claim or a WTC-related health
condition that is not work related and the enrollee is covered by a
public or private health insurance plan (with the exception of
Medicare). Pub. L. No. 111-347, 124 Stat. 3653 (adding PHSA § 3331).
The workers' compensation exception does not apply when responders are
covered under a workers' compensation plan administered by New York
City.
[7] With one exception, the entities that were awarded contracts for
operating clinical centers for the WTCHP are the same as those that
served as clinical centers for the FDNY WTC program and the NY/NJ WTC
Consortium. NIOSH awarded a contract to the Long Island Jewish Medical
Center, which did not previously have a contract as a clinical center.
According to a CDC official, Long Island Jewish Medical Center will
have a partnership with Queens College, which was a clinical center
for the NY/NJ WTC Consortium prior to July 1, 2011. The entities
awarded contracts to operate the data centers for the WTCHP are the
same as those that served as the DCCs for the FDNY WTC program and the
NY/NJ WTC Consortium. In addition, NIOSH awarded a task order not to
exceed $79,830,170 to Computer Sciences Corporation for overall
program administration, business communications, and information
systems implementation of the WTCHP. This task order includes the
services of a pharmacy benefit manager--an entity that negotiates
rebates and payments with manufacturers, negotiates prices with retail
pharmacies, and can provide other related administrative and clinical
services--for the WTCHP's prescription drug plan.
[8] Pub. L. No. 111-347, 124 Stat. 3657 (adding PHSA § 3351). The act
specifies that the federal share of the funding for the WTCHP will be
the lesser of either 90 percent of the actual expenditures each year
or an amount specified for each year. The act also provides that a 10
percent NYC share shall be deposited into the WTCHP Fund and that
disbursements from the WTCHP Fund are conditioned on NYC contracting
to contribute a 10 percent share of actual expenditures.
[9] Pub. L. No. 111-347, 124 Stat. 3631, 3646-48 (adding PHSA §§
3305(a)(5), 3312(c)(B)(iv), and 3313(d)(2)). The Zadroga Act includes
an additional GAO mandate requiring an analysis of whether the
Clinical Centers of Excellence (CCE) with which the WTCHP enters into
a contract have financial systems that will allow for the timely
submission of claims data as envisioned by the act. Pub. L. No. 111-
347, 124 Stat. 3633 (adding PHSA § 3305(d)). See GAO, World Trade
Center Health Program: Administrator's Plans for Evaluating Clinics'
Capability to Provide Required Data, [hyperlink,
http://www.gao.gov/products/GAO-11-793R] (Washington, D.C.: Jul. 15,
2011).
[10] The WTC Steering Committee consists of the principal
investigators from each WTC clinical center, the principal
investigators from each DCC, an external advisory committee
representative, a chairperson appointed by NIOSH, and other, nonvoting
members. The WTC Steering Committee was intended to develop and ensure
compliance with clinical policies and procedures, evaluate protocols
proposed by the clinical centers, and ensure that studies were
properly conducted and study results were reported and disseminated to
the scientific community, including physicians involved in the care of
WTC responders, in a timely manner.
[11] LHI designs, implements, and manages occupational health services
and medical and dental services for the U.S. military and HHS, as well
as for commercial companies.
[12] VAMCs provide a wide range of services, including outpatient,
mental health, and critical care; surgery; and pharmacy. In addition,
most VAMCs offer additional medical and surgical specialty services,
such as neurology. A CBOC is associated with, but geographically
separate from, a parent VAMC, and can provide primary, specialty,
subspecialty, and mental health care, or any combination of health
care delivery services that can be appropriately provided in an
outpatient setting. Other outpatient clinics in the VA health system
include IOCs, which are freestanding ambulatory care clinics. In
contrast to CBOCs, IOCs are not associated with VAMCs.
[13] We calculated the straight-line distance between ZIP codes and
did not account for factors that might affect travel distances or
travel time.
[14] The seven prescription drug plans included those of the FDNY WTC
program, each of the five clinical centers of the NY/NJ WTC
Consortium, and the WTC National Responder Health Program.
[15] TRICARE is a regionally structured program that uses contractors
to maintain provider networks to complement health care provided at
military treatment facilities. The 340B Drug Pricing Program provides
eligible entities, such as health centers and hospitals that provide
comprehensive health care services for a high proportion of low-income
patients, with access to discounted drug prices.
[16] We included the federal prescription drug purchasing programs for
which an arrangement with HHS to provide prescription drugs to WTC
responders seemed the most feasible.
[17] A formulary is a list of drugs that a health care organization
has determined to be the most medically appropriate and cost-effective
for its patient population.
[18] To identify the drugs that were on the formularies used by VA and
TRICARE and were available through the 340B program, we used the VA
National Formulary published on its Web site in January 2011 (accessed
March 10, 2011), the TRICARE Formulary Search Tool available on DOD's
Web site (accessed June 2, 2011), and the 340B Prime Vendor Program
Catalog (accessed May 17, 2011). According to HRSA, the 340B Prime
Vendor Program Catalog does not include all prescription drugs
available through the 340B Drug Pricing Program.
[19] See Department of Defense Appropriations Act, 2006, Pub. L. No.
109-148, § 5011(b), 119 Stat. 2680, 2814 (2005).
[20] Since November 2002, NIOSH has implemented various forms of a
national program for responders outside the NYC area, although no
program existed from August 2004 until June 2005. See GAO, September
11: HHS Needs to Ensure the Availability of Health Screening and
Monitoring for All Responders, GAO-07-892 (Washington, D.C.: Jul. 23,
2007).
[21] According to NIOSH, responders who meet eligibility criteria can
be enrolled in the program; however, not all individuals participate
in their respective programs after enrolling.
[22] NIOSH reports current data on the numbers of responders screened,
monitored, and treated on its Web site: [hyperlink,
http://www.cdc.gov/niosh/topics/wtc/census.html] (accessed June 17,
2011).
[23] FDNY's Bureau of Health Services provides health services for all
FDNY employees and also provided screening, monitoring, and treatment
services for the FDNY WTC program.
[24] Pub. L. No. 111-347, 124 Stat. 3630 (adding PHSA § 3305(a)(2)).
[25] GAO, September 11: World Trade Center Health Programs Business
Process Center Proposal and Subsequent Data Collection, [hyperlink,
http://www.gao.gov/products/GAO-11-243R] (Washington, D.C.: Dec. 3,
2010).
[26] GAO, Opportunities to Reduce Potential Duplication in Government
Programs, Save Tax Dollars, and Enhance Revenue, [hyperlink,
http://www.gao.gov/products/GAO-11-318SP] (Washington, D.C.: Mar. 1,
2011) and GAO, Opportunities to Reduce Potential Duplication in
Government Programs, Save Tax Dollars, and Enhance Revenue,
[hyperlink, http://www.gao.gov/products/GAO-11-441T] (Washington D.C.:
Mar. 3, 2011).
[27] Office of Management and Budget, Memorandum for Chief Information
Officers: Update on the Federal Data Center Consolidation Initiative
(Washington, D.C.: October 2010).
[28] [hyperlink, http://www.gao.gov/products/GAO-11-318SP].
[29] According to NIOSH, about 3,700 responders had been screened by
the WTC National Responder Health Program as of March 31, 2011.
[30] UMR is a subsidiary of UnitedHealthcare (a UnitedHealth Group
company). UMR provides integrated health benefit management for
dental, vision, disability, and medical plans. Under the subcontract,
UMR reviews claims and responders have access to treatment services
through UnitedHealthcare's national network of health providers.
[31] Pub. L. No. 111-347, 124 Stat. 3647 (adding PHSA § 3313). NIOSH
officials told us that the agency will use LHI to meet the
requirements of the act in the near term. Under the Zadroga Act,
responsibilities for providers participating in the national network
include collecting and reporting data in accordance with specified
standards; following certain monitoring, screening, and treatment
protocols; and meeting criteria for credentialing to be established by
data centers. In addition to responders, community members (referred
to as "survivors") will be eligible for services in the national
network.
[32] Not all veterans, however, have the same priority for receiving
health services in VA facilities. Veterans are assigned to priority
groups based on certain factors, such as service-connected disability
status and income.
[33] One of the Consortium's clinical centers did not independently
contract with a PBM and provided prescription drugs to WTC responders
through an in-house pharmacy. Of the remaining six WTC prescription
drug plans, three plans received discounts from retail pharmacies or
rebates from manufactures through their PBMs and three plans did not.
[34] Pub. L. No. 111-347, 124 Stat. 3646 (adding PHSA § 3312(c)(1)(B)).
[35] Some federal programs set ceiling prices, others establish prices
by referencing prices negotiated by private payers in the commercial
market, and others rely on negotiations with manufacturers, either
directly or through private health plans. See GAO, Prescription Drugs:
An Overview of Approaches to Negotiate Drug Prices Used by Other
Countries and U.S. Private Payers and Federal Programs, GAO-07-358T
(Washington, D.C.: Jan. 11, 2007).
[36] The formulary does not apply to the CHAMPVA program.
[37] Entities eligible to enroll in the 340B Drug Pricing Program are
specified in statute and include certain health centers and hospitals
that provide comprehensive health care services for a high proportion
of low-income patients, as well as programs that serve patients with
specific conditions or diseases. See 42 U.S.C. § 256b(a)(4). Not all
eligible entities choose to enroll in the program. The categories of
entities that are eligible to participate in the program have been
expanded over time.
[38] The WTC responder health programs were not independently eligible
for the 340B Drug Pricing Program. The Bellevue and Mt. Sinai clinical
centers are located within hospitals that meet current eligibility
criteria and are enrolled in the program.
[39] Chief Information Officers Council, Memorandum for Chief
Information Officers: Federal Data Center Consolidation Initiative
Initial Plans, [hyperlink,
http://cio.gov/documents/fddci-initial-plan-memo-5-26.pdf] (accessed
June 24, 2011); and Chief Information Officers Council, Cracking Down
on Wasteful, Duplicative Spending, [hyperlink,
http://www.cio.gov/pages.cfm/page/Cracking-Down-on-Wasteful-
Duplicative-Spending] (accessed May 9, 2011).
[40] [hyperlink, http://www.gao.gov/products/GAO-11-318SP], p. 67-68.
[41] Ibid.
[42] For example, in September 2010, the Office of Inspector General
in the Department of Homeland Security, a federal agency involved in
the FDCCI, reported that the department's consolidation efforts would
cost about $560 million. See U.S. Department of Homeland Security.
Office of Inspector General, Management of DHS' Data Center
Consolidation Initiative Needs Improvement (Washington, D.C.:
September 2010), 5.
[43] If access to data were lost it would be difficult for researchers
to conduct analyses examining the progression of WTC-related
conditions in responder populations over time.
[44] [hyperlink, http://www.gao.gov/products/GAO-11-318SP], p. 67.
[45] As of March 19, 2011, the NY/NJ WTC Consortium DCC database
included ZIP codes and states for 4,368 of the 4,621 WTC responders
living outside the NYC area. We conducted our analysis on these 4,368
responders.
[46] As of September 30, 2010, VA's database included 739 CBOCs and 5
IOCs. For this analysis, we included the IOCs with the CBOCs.
[47] According to VA officials, larger CBOCs are required by VA to
have on-site mental health services, and other CBOCs use telehealth to
offer such services. Telehealth services are provided from a distance
using telecommunications technologies, such as videoconferencing.
[48] Some responders might be able to continue seeing their LHI or
UnitedHealthcare provider. According to VA officials, it might be
possible to provide some responders with access to non-VA providers on
a fee-for-service basis if they do not live near a VA facility or
cannot access services in nearby VA facilities.
[49] See 38 U.S.C. § 8126(a)(2), (c), (d).
[50] NIOSH awarded a task order to Computer Sciences Corporation that
includes the services of a pharmacy benefit manager to administer the
prescription drug benefit for all of the WTCHP responders in the NYC
area. A NIOSH official told us that the PBM will negotiate rebates
with manufacturers and drug prices with retail pharmacies as part of
its contract with NIOSH. The official told us that prescription drugs
for WTC responders residing outside the NYC area will continue to be
provided through the LHI contract in the near term. The PBM used by
LHI currently negotiates rebates with manufacturers and drug prices
with retail pharmacies for the WTC National Responder Health Program.
[51] It is uncertain whether an in-house pharmacy option will be
available through the WTCHP.
[52] A VA official told us that some CBOCs have contracts with retail
pharmacies for VA beneficiaries to access prescription medications in
an emergency and that a small number of prescriptions are filled this
way.
[53] VA fills prescriptions for nonformulary drugs for CHAMPVA
beneficiaries without prior approval.
[54] TRICARE's formulary includes all 29 of the drugs that were most
frequently used by WTC responders in 2010; however, either prior
authorization or proof of medical necessity is required to obtain 6 of
the 29 drugs.
[55] Twenty-eight of the 29 prescription drugs most frequently used by
WTC responders in 2010 were 340B-covered drugs.
[End of section]
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