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entitled 'September 11: HHS Needs to Ensure the Availability of Health 
Screening and Monitoring for All Responders' which was released on July 
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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. 

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