The Lack of Timely, Accurate Information Has Delayed HRSA’s Redistribution of Funds and Places at Risk HRSA’s Ability to Obligate Funds in the Required Time Frame

The lack of timely and accurate information in grantees’ FSRs regarding  grant year 2007 unobligated balances has delayed HRSA’s distribution of  Part B supplemental grants, and places at risk HRSA’s ability to  redistribute these funds by September 30, 2009, after which it will no  longer have the authority to redistribute the funds. HRSA officials stated that due to grantees’ difficulty  tracking funds separately, some grantees’ FSRs reported inaccurate  unobligated balances, which required HRSA staff to correspond with  grantees and request revised information, creating additional delays. HRSA Has Taken Actions to Collect Client-Level Data, but Some Grantees Did Not Submit Initial Reports by the Deadline

HRSA has taken actions to collect client-level data by implementing a new  data collection and reporting system. HRSA stated that RSR will improve information on the clients served, the  services provided to clients, and the outcomes of the services provided. RSR is designed to provide HRSA with a more accurate measure of the  number of unique clients receiving CARE Act-funded services by assigning  each individual an encrypted Unique Client Identifier thereby allowing the  tracking of individuals who receive services from multiple providers. RSR is part of a process through which HRSA plans to collect information,  including client-level data, from grantees and service providers funded  under CARE Act Parts A, B, C, D, and F. First, the grantees and service  providers collect data using their own data collection systems. HRSA Has Provided Financial and Technical Assistance to Grantees to Develop Their Own Client- Level Data Collection and Reporting Systems

HRSA provided financial assistance to CARE Act grantees to develop or  adapt their client-level data collection and reporting systems so that they  could submit the required information to RSR. Under the fiscal year 2009 SPNS  initiative, HRSA awarded a total of approximately $4 million to all 57   Parts C and D grantees that applied for funding. Two of these health departments received  $200,000 each. For  example, officials from three health departments stated they were  concerned about how to train service providers and other partners to  collect client-level data. Table 2 provides a  description of the reports to be submitted to RSR by grantees and service  providers and the deadline for the initial reporting period for each report. The Number and Size of ADAP Waiting Lists Is Increasing

The number of individuals on ADAP waiting lists increased during grant  year 2008 and has continued to increase in 2009. In the first quarter of  grant year 2008 (April 1, 2008, through June 30, 2008), 2 ADAPs had  waiting lists with a total of 55 people on those lists. In the fourth quarter of  grant year 2008 (January 1, 2009, through March 31, 2009), there were 3  ADAPs with waiting lists, but the number of individuals on the lists had  increased to 112. Kentucky,  Montana, Nebraska, and Wyoming all had waiting lists in August 2009. Nebraska had the largest ADAP waiting list with 71 individuals while  Wyoming had the smallest list with 5 individuals. Table 3 lists the grantees with ADAP waiting lists and the number  of individuals on those lists. For example, Hawaii officials expressed  concern that they will have to establish a waiting list. As a result of the  requirement to cancel unobligated balances and, in some cases, penalize  grantees, HRSA implemented complex processes that have been difficult  for grantees to comply with, thus delaying HRSA’s first implementation of  the requirement. Because  funds for these grants are only available until September 30, 2009, HRSA is  at risk of losing the authority to make these grants. HRSA officials told us that, for grant years 2008 and 2009, they have  changed their process for implementing the unobligated balance  provisions in order to alleviate the burden on staff and to ensure that  HRSA has the information it needs to implement the unobligated balance  provisions in a timely manner. We are sending copies of this report to the Secretary of Health and Human  Services.
Why GAO Did This Study

Under the CARE Act, funds are made available to assist over 530,000 individuals affected by HIV/AIDS. Grantees directly provide services to individuals (clients) or arrange with service providers to do so. The Department of Health and Human Services's (HHS), Health Resources and Services Administration (HRSA), which administers CARE Act programs, is required to cancel balances of grants that are unobligated after one year and redistribute amounts to grantees in need. HRSA began to collect client-level data in 2009. Under the CARE Act, states and territories receive grants for AIDS Drug Assistance Programs (ADAP), which provide HIV/AIDS drugs. GAO was asked to examine elements of the CARE Act. In this report, we review: (1) HRSA's implementation of the unobligated balance provisions, (2) HRSA's actions to collect client-level data, and (3) the status of ADAP waiting lists. GAO reviewed reports and agency documents and interviewed federal officials, officials from 13 state and 5 local health departments chosen based on location and number of cases, and other individuals knowledgeable about HIV/AIDS.

What GAO Found

The lack of timely and accurate information reporting by grantees has delayed HRSA's distribution of certain grants and has placed at risk HRSA's ability to obligate these funds. The late submission of actual unobligated balances for the 2007 grant year delayed HRSA's ability to determine grantees' unobligated balances and redistribute these funds to other grantees. A number of grantees were late in their submissions. For example, 21 of the 56 metropolitan areas submitted their information beyond the date initially set by HRSA. Additionally, some grantees reported inaccurate unobligated balances, which required HRSA staff to correspond with grantees and request revised information, creating additional delays. HRSA is authorized to obligate fiscal year 2007 funds for a 3-year period and is at risk of losing the authority to make grants from these funds. HRSA officials said they have made changes to how they implement the unobligated provisions in an effort to avoid these issues in the future. HRSA has taken actions to collect client-level data by implementing a new data collection and reporting system. However, some grantees and service providers did not submit the initial reports by HRSA's deadline. HRSA set a July 31, 2009, submission deadline for grantees' initial reports, but 100 of 638 grantees did not meet this deadline. Client-level data includes information such as the dates clients were served, the types of services provided, and the clients' health status. HRSA has implemented a system to collect data on the number of unique clients from grantees and service providers that will allow HRSA to determine the services each client received and the outcomes of these services. In order for HRSA to collect this information, grantees and service providers must first collect the data using their own systems, and HRSA has provided technical and financial assistance so that they can develop these systems. For example, under a project initiated in 2009, HRSA awarded approximately $4 million to CARE Act grantees for the development of their own client-level data collection systems. The number of ADAPs with waiting lists and the number of individuals on those lists is increasing. In the first quarter of grant year 2008 (April 1, 2008, through June 30, 2008), 2 ADAPs had waiting lists with a total of 55 people on those lists; this grew to 3 ADAPs and a total of 112 people in the fourth quarter of the year, and increased to 4 ADAPs and 136 individuals in August 2009. Kentucky, Montana, Nebraska, and Wyoming were each maintaining a waiting list for ADAP services in August 2009; Nebraska had the largest number of individuals (71), and Wyoming had the smallest number (5). ADAP officials expressed concern that they will have to establish or expand waiting lists or implement other cost-control measures, such as limiting the number of drugs they make available.