prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 1.



Report 2: As of June 30, 2017, the UN had carried out 71 peacekeeping operations since 1948, and had 16 active UN peacekeeping operations worldwide  Eight of these UN peacekeeping operations were in sub-Saharan Africa (see fig  1)  In their earliest days, UN peacekeeping operations were primarily military in nature and limited to monitoring cease-fire agreements and stabilizing situations on the ground while political efforts were being made to resolve conflicts  Today, in response to increasingly complex situations in which conflicts may be internal, involve many parties, and include civilians as deliberate targets, UN peacekeeping operations are more commonly “multidimensional”—deploying civilian and police personnel in addition to military personnel  Multidimensional peacekeeping operations seek to create a secure and stable environment while working with national authorities and actors to make sure the peace agreement or political process is implemented  According to the UN, multidimensional peacekeeping operations are designed to protect civilians and often assist in the disarmament, demobilization and reintegration of former combatants; support the organization of elections; protect and promote human rights; and assist in restoring the rule of law  Figure 2 shows examples of UN peacekeepers serving in different capacities as part of MINUSCA in Bangui, CAR  Each UN peacekeeping operation, including its mandated size and tasks, is authorized through a UN Security Council resolution  The operation’s budget and resources are subject to General Assembly approval  The UN’s approved budget for global peacekeeping operations in UN fiscal year 2017 was about $7 9 billion  Individual operation budgets ranged from about $36 million for the peacekeeping operation in Kosovo to more than $1 2 billion for the peacekeeping operation in the Democratic Republic of the Congo (see table 1)  The UN reported in June 2017 that it maintained 95,544 uniformed peacekeepers, 5,004 international civilians, 10,149 local civilians, and 1,597 UN volunteers in support of its operations around the world  According to UN documents, civilian peacekeeping personnel are generally recruited to peacekeeping operations as individuals, while police and military personnel are volunteered by member states to participate as part of their country’s contribution to UN peacekeeping operations  The United States is the largest financial contributor to UN peacekeeping operations  From fiscal years 2014 to 2017, the United States contributed an average of about $2 1 billion per year to these operations  The UN General Assembly sets the assessment levels for UN member contributions to peacekeeping operations every 3 years  The United States’ assessment has averaged about 28 5 percent of the UN peacekeeping budget; however, Congress has authorized payment with appropriated funds at about 27 percent for U S  fiscal years 2014 through 2016, and 25 percent for U S  fiscal year 2017  In April 2014, UN Security Council Resolution 2149 established MINUSCA following escalating sectarian violence in CAR that resulted in the destruction of state institutions, thousands of deaths, and 2 5 million people—more than half of CAR’s entire population—in need of humanitarian aid, according to a UN report  The conflict also resulted in 174,000 people being internally displaced and over 400,000 fleeing to neighboring countries, according to the UN report  MINUSCA’s tasks include protecting civilians, given the security, humanitarian, human rights, and political crisis in CAR; supporting the implementation of the transition process, including efforts to extend state authority and preserve territorial integrity; facilitating the delivery of humanitarian assistance and promoting and protecting human rights; supporting justice and the rule of law; and facilitating the disarmament, demobilization, reintegration, and repatriation processes  On November 15, 2017, UN Security Council Resolution 2387 (2017) extended MINUSCA’s mandate for a fourth time, through November 15, 2018  MINUSCA’s approved personnel levels for UN fiscal year 2017 comprised 10,750 military personnel, 400 individual police officers, and 1,680 formed police unit personnel, as well as 790 international civilian and 696 national civilian personnel, 238 UN volunteers, and 40 government- provided personnel, according to a UN Secretary-General report  Table 2 shows average annual personnel deployment for MINUSCA and the number of authorized positions for the first 3 full fiscal years of the operation  Based on data and other input from the UN, DOD, and State, we estimate that it would cost the United States more than twice as much as it would cost the UN to implement a hypothetical operation comparable to MINUSCA, the ongoing UN operation in the Central African Republic (CAR)  In addition, the estimated cost of a U S  operation in CAR far exceeds U S  contributions to MINUSCA  Based on an estimate we developed in conjunction with DOD and State officials, a hypothetical, comparable U S  operation would likely cost nearly $5 7 billion, more than twice as much as MINUSCA, the ongoing UN operation in CAR  Our comparison covers the time from which MINUSCA was established in April 2014 through the end of UN fiscal year 2017, which ended on June 30, 2017—a total of 3 years and 3 months, the first 39 months of MINUSCA  Over this time period, UN costs for MINUSCA totaled approximately $2 4 billion  Using roughly the same basic parameters for MINUSCA, including similar deployment levels of military and civilian personnel over the same time period, in consultation with DOD and State officials, we estimate that a comparable, hypothetical U S  operation would likely cost nearly $5 7 billion, more than twice the UN cost for MINUSCA (see table 3 for a detailed comparison of estimated U S  costs and actual UN costs)  This estimate does not include, among other things, the cost for State diplomatic security and office space for civilian staff, the inclusion of which could further increase the total estimated U S  cost for such an operation  During the same time period, from April 10, 2014 through June 30, 2017, the United States contributed approximately $700 million to the UN to support MINUSCA  Therefore, the estimated cost of a U S  operation (nearly $5 7 billion) would be almost eight times greater than the United States’ contribution to MINUSCA  See figure 3 for a comparison of these costs with the U S  estimate  Various factors contribute to the differences in costs between actual UN expenditures for MINUSCA from April 10, 2014 through June 30, 2017— the first 39 months of MINUSCA—and a hypothetical, comparable U S  operation over the same time period, including disparities in the cost of sourcing and transporting equipment and supplies, staffing and compensating military and police personnel, and maintaining facilities and communications and intelligence systems  These disparities reflect operational, structural, and doctrinal differences in the way the United States likely would undertake a hypothetical, comparable operation, should such an operation be deemed in the U S  national interest  High U S  costs to source and transport supplies and equipment to the Central African Republic (CAR) contribute to the difference between our cost estimate for the hypothetical U S  peacekeeping operation and the UN’s actual costs for MINUSCA  In the hypothetical U S  operation, based on input from DOD and IDA officials and the output of the IDA cost estimating tool, the United States would fly in most of its consumable supplies from outside CAR  Specifically, materials such as water, ice, food, and other subsistence items would be airlifted into CAR from Italy, a supply location validated as reasonable by DOD and IDA officials given its proximity to the operation and because MINUSCA relies on a UN global service center there, one of two such UN centers in Europe  The estimated U S  cost of airlifting water alone over the 39-month time period for the hypothetical operation would total nearly $700 million  The United States would still deploy its equipment and personnel to CAR from the United States, at a cost of nearly $600 million  Transportation of equipment and supplies within CAR would cost an additional estimated $316 million  In contrast, the UN does not fly in water or consumables on the same scale as the United States would in the hypothetical operation  Instead, the UN relies on some in-country or local infrastructure and consumables  Military and formed police unit equipment is provided by the troop- and police-contributing countries  The UN reimburses these countries for equipment at set rates  The UN cost of reimbursing countries for deploying their equipment to CAR likely would be less than the amount the United States would spend on airlifting the equipment to CAR alone  For example, the UN cost of freight, deployment, and country reimbursements for military and formed police equipment was approximately $229 million over a 2-year period (July 2014 through June 2016), while in the hypothetical operation the U S  cost of deploying equipment alone would be over $382 million, which is about $154 million more than the UN cost over a similar 2-year period (September 2014 through August 2016)  The United States would staff and compensate its military and police personnel differently than the UN, leading to differences between the estimated U S  costs and actual UN costs  While neither the hypothetical U S  cost estimate nor UN expenditures include the cost of salaries for active duty personnel or troops contributed by other countries, respectively, the United States would bear the additional cost of salaries for the share of personnel drawn from military reserves  According to DOD officials, 10 percent of infantry unit personnel would have been reservist personnel in a hypothetical, comparable U S  operation, based on the average ratio of active to reserve personnel deployed by the United States in fiscal years 2015 through 2017, roughly the same time period as the first 39 months of MINUSCA  As a result, the total estimated cost of the hypothetical U S  operation reflects the additional U S  expense of paying full salaries and hardship duty pay for U S  reservist military personnel  The estimate also includes the incremental costs the United States would incur for deploying active duty military personnel, including hardship duty pay that is not incurred when those personnel are in the United States  For military troops deployed to MINUSCA, the UN pays a standard troop cost reimbursement to the troop-contributing countries, which is intended also to cover incremental expenses but not the cost of troops’ salaries  U S  costs for civilian police also are significantly higher than UN costs  The United States would pay over $167 million for U S  civilian police for the duration of the hypothetical operation, while the UN spent $41 million on its individual police officers over the same time frame  The U S  estimate includes the cost of police salaries and the additional costs of deployment, whereas UN costs for deploying individual police officers do not include salaries, which are borne by the police-contributing countries  Higher U S  standards for certain aspects of the hypothetical peacekeeping operation in CAR would contribute to costs that exceed those of MINUSCA  Facilities  The higher estimated U S  costs reflect higher U S  standards for facilities, according to State officials  The U S  cost estimate includes more than $1 1 billion for facilities and related costs, which include facility maintenance, food service, laundry, management and administration, and residential leases for civilian personnel  In contrast, the actual UN cost for facilities as part of MINUSCA totaled $292 million over the same time period  Communications and intelligence systems  The United States incurs costs associated with meeting U S  intelligence standards that are not part of UN operations, which lack comparable intelligence capabilities  The U S  cost estimate includes $140 million for the cost of Command, Control, Communications, Computers, and Intelligence Systems, which represents additional operational costs to meet higher U S  standards for U S  communications and intelligence capabilities  Medical capability  Higher U S  standards for medical care and medical evacuation capability as compared to the UN are another factor that would contribute to higher U S  medical costs for a hypothetical operation, according to DOD and State officials  Some UN hospitals may not meet U S  minimum standards for medical care, according to DOD officials  Although medical costs do not constitute a significant portion of the U S  cost estimate, estimated U S  medical costs ($132 million) greatly exceed actual UN medical costs ($8 million) over the same time period  UN and U S  peacekeeping operations have various relative strengths, according to U S  and UN officials we met with  Relative strengths of UN peacekeeping operations include international and local acceptance, access to global expertise, and the ability to leverage assistance from multilateral donors and development banks, according to these officials  Relative strengths of U S  peacekeeping operations would include faster deployment and superior command and control, logistics, intelligence, and counterterrorism capabilities, according to U S  and UN officials  According to U S  and UN officials, UN peacekeeping operations benefit from greater international and local acceptance, access to global expertise, and the ability to leverage assistance from multilateral donors and development banks  UN peacekeeping operations also provide indirect benefits to the military capacity of participating countries  International and local acceptance  As a multilateral organization, the UN benefits from greater international and local acceptance for its peacekeeping operations, according to State, DOD, and UN officials  These officials noted that the UN’s multinational character contributes to a reputation for local impartiality  Conversely, the United States acting alone may not be viewed as impartial and could face challenges gaining or maintaining international or local support for peacekeeping operations, according to State and DOD officials  Global expertise  UN officials noted that the UN has unmatched convening power and access to expertise and experience from across the globe to implement the objectives of multidimensional peacekeeping operations  The UN is able to bring in people with subject matter expertise, native language skills, and knowledge of local customs to work for these operations, according to U S  and UN officials  Leveraging multilateral assistance  U S  officials told us that the UN is better able to leverage assistance from multilateral donors and multilateral development banks to expand the scope of assistance provided in support of the goals of peacekeeping operations  For example, according to a UN report, MINUSCA is partnering with the UN Development Fund to provide capacity building related to elections, police, courts, and prisons  The report also noted that the UN, European Union, and World Bank supported the Central African Republic government in developing a “National Recovery and Peacebuilding Plan” while harmonizing humanitarian and development funding to ensure complementarity with the UN peacekeeping operation
Report 2:  Federal internal control standards state that management should share quality information throughout an organization to enable personnel to perform key roles, and we have previously reported that by regularly sharing useful performance information with leaders at multiple levels of an organization, agencies can help leaders make informed decisions  Without this information, individual unit commanders or the commanders’ supervisors cannot determine whether Coast Guard servicemembers under their command completed TAP or identify whether there is a need for corrective actions to ensure they do so  As we mention earlier in this report, the Coast Guard plans to adopt DOD’s TAP-IT Enterprise System, which according to officials, could help the Coast Guard ensure eligible servicemembers participate in the program  According to a Coast Guard official, once the system is fully implemented by the Coast Guard, commanders will be required to verify and document whether Coast Guard servicemembers under their command completed TAP, potentially making commanders more vested in the process  We previously reported that a senior DOD official said that the TAP-IT Enterprise System may be able to generate unit- and installation-level reports for the four DOD-led military services by October 2018, and a Coast Guard official said he would work with DOD to identify whether this capability could also extend to the Coast Guard  Once data reliability improves, sharing installation and unit-level TAP performance information with Coast Guard commanders could support monitoring efforts  The performance measures tracked by the TAP interagency working group do not reflect TAP implementation broadly across all five military services, according to a Coast Guard official we interviewed  The Coast Guard does not currently share TAP data it collects with DOD or other members of the interagency performance working group  While the benefits of interagency data sharing cannot be realized without the Coast Guard first improving the quality and completeness of its TAP data, we have identified leading practices for interagency collaboration, including that members of interagency working groups identify and share relevant agency performance data  Moreover, federal internal control standards call for management to communicate quality information to external parties  Because the Coast Guard does not share TAP data, the performance measures tracked by the interagency group do not reflect Coast Guard servicemembers’ experiences and thus do not provide a complete picture of TAP implementation across the five military services  More specifically for the Coast Guard, without such data sharing, future TAP evaluations may not be able to assess the effectiveness of TAP delivery, hindering the Coast Guard’s ability to make program adjustments to better prepare its servicemembers to successfully transition to life after military service  Coast Guard officials said migrating to DOD’s TAP-IT Enterprise System will facilitate information sharing with interagency partners and that improving data completeness and reliability is a top priority for 2018  Given the sacrifices servicemembers have made to serve their country, it is imperative they are afforded every chance to adequately prepare for civilian life before leaving military service  In order to make a successful transition, servicemembers need to be well-positioned to get a job or make an informed decision about whether to pursue additional education or start a small business  As such, the Transition Assistance Program (TAP) serves a critically important function—to give servicemembers the tools and information they need to successfully transition to life outside the military  Federal law requires that the Coast Guard ensure all eligible servicemembers participate in the program, but thousands of Coast Guard servicemembers may have transitioned without the support provided by TAP  Reliably tracking participation has proven to be a challenge for the Coast Guard, in part because it lacks a current Commandant Instruction that defines the roles and responsibilities of staff responsible for implementing TAP and ensuring complete and reliable data are collected  In preparing to issue an updated Commandant Instruction, the Coast Guard has taken a positive step toward addressing the limitations of its current TAP data, and will be better positioned to ensure compliance with VOW Act requirements using reliable data  In addition to collecting reliable data, the Coast Guard could further demonstrate its commitment to meeting TAP requirements by establishing formal performance goals that measure the extent to which Coast Guard servicemembers participate in TAP  By establishing interim performance goals, the agency would be able to show its progress towards achieving full compliance  Moreover, communicating performance goals to unit and installation commanders could enhance accountability and might spur progress toward meeting federal program requirements  By expanding its monitoring efforts beyond tracking participation in TAP’s required classes, the Coast Guard could enhance its ability to ensure other TAP requirements are met and that its servicemembers are able to access additional transition resources  Monitoring the timeliness of participation would help ensure Coast Guard servicemembers have adequate time to complete TAP before leaving the military  Further, by monitoring requests to participate in additional 2-day classes and 2-day class attendance, the Coast Guard would be in a better position to identify whether servicemembers who wish to attend the classes are able to do so, to determine whether more classes are needed, and to communicate this information to the interagency partners responsible for delivering these classes  Commanders can also play a key role in bolstering TAP participation  Having an up-to-date written Commandant Instruction that explicitly describes commanders’ roles and responsibilities could enhance commanders’ ability to ensure TAP’s proper implementation and compliance with VOW Act requirements  Moreover, once data quality improves, providing commanders a mechanism to readily determine whether servicemembers under their command have completed TAP could help them monitor the program to ensure that all TAP-eligible servicemembers receive the resources they need to successfully transition to civilian life  Finally, once more reliable data on Coast Guard servicemember participation are available, sharing this information with interagency partners could improve TAP implementation on a broader scale  Sharing reliable data, such as participation figures for the Coast Guard, would give TAP interagency partners a more complete picture of implementation across all five military services  Sharing such information would also enhance the interagency group’s ability to evaluate how well TAP serves the entire population of servicemembers  Improving the reliability of the Coast Guard’s TAP data will be essential for the benefits of data sharing to be realized  To ensure that all eligible Coast Guard servicemembers are provided the opportunity to complete the Transition Assistance Program (TAP), we recommend the Commandant of the Coast Guard take the following seven actions: Issue an updated Commandant Instruction that establishes policies and procedures to improve the reliability and completeness of TAP data by including when and by whom data should be recorded and updated  (Recommendation 1) Establish a formal performance goal with a measurable target for participation rates in VOW Act-mandated portions of TAP  (Recommendation 2) Monitor the extent to which Coast Guard servicemembers participate in TAP within prescribed time frames  (Recommendation 3) Monitor the extent to which Coast Guard servicemembers who elect to participate in additional 2-day classes are afforded the opportunity to attend  (Recommendation 4) Issue an updated Commandant Instruction that defines the roles and responsibilities of the personnel who administer the program and ensure servicemembers’ participation  (Recommendation 5) Once reliable data are available by installation or unit, enable unit commanders and the higher-level commanders to whom they report to access TAP performance information specifically for the units they oversee so that they can monitor compliance with all TAP requirements  (Recommendation 6) Once reliable data are available, share TAP information with DOD and other interagency partners, such as data on participation in required TAP courses and additional 2-day classes  (Recommendation 7) We provided a draft of this report to the Departments of Homeland Security, Defense, Education, Labor, and Veterans Affairs, the Office of Personnel Management, and the Small Business Administration for their review and comment  The formal written response of the Department of Homeland Security (DHS) is reproduced in appendix II  In addition, DHS provided technical comments from Coast Guard officials that we incorporated into the report as appropriate  The other agencies did not provide any comments  In its written comments, DHS agreed with all seven of our recommendations  If you or your staff have any questions about this report, please contact me at (202) 512-7215 or brownbarnesc@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 key contributions to this report are listed in appendix III  This report examines (1) what is known about the reliability of Transition Assistance Program (TAP) data on participation levels and the factors that affect Coast Guard servicemembers’ participation, and (2) the extent to which the Coast Guard measures TAP performance and monitors key areas of TAP implementation  To address these questions, we surveyed Coast Guard installations with full-time TAP operations; reviewed Coast Guard data on TAP participation for fiscal years 2012 to 2017; visited one Coast Guard installation and interviewed TAP managers from two additional Coast Guard installations selected for diversity in location, among other reasons; and interviewed Coast Guard officials responsible for overseeing TAP implementation for the Coast Guard  We also reviewed relevant federal laws, regulations, policies, documents, and publications  Information in this report is current as of the date GAO received formal agency comments from DHS  Our survey of Coast Guard installations with full-time TAP operations asked about how TAP was being implemented  The survey included questions about the accessibility of TAP components, challenges Coast Guard servicemembers faced in attending the components, and the level of commander support for participation  Our survey targeted front-line TAP managers, who could draw on the expertise of TAP course facilitators, transition counselors, career counselors, and other key TAP staff as necessary  After drafting the survey questions, we pretested them with a TAP manager to ensure (1) the questions were clear and unambiguous, (2) terminology was used correctly, (3) the survey did not place an undue burden on agency officials, (4) the information could feasibly be obtained, and (5) the survey was comprehensive and unbiased  We revised the content and format of the survey based on the feedback we received  We initially sent the survey to TAP managers at all 13 Coast Guard installations at which TAP staff were located  We removed one installation when we later found that the TAP manager position was vacant and revised the total to 12 Coast Guard installations  The survey was accessible online from October 31, 2016, through January 18, 2017, through a secure server that recipients were able to access using unique usernames and passwords  We sent an email announcement to TAP staff at all 13 Coast Guard installations at which TAP staff are located on October 24, 2016  We sent a second email on October 31, 2016 to notify participants the survey was available online, and provided their unique passwords and usernames  We sent two follow-up e-mails (November 14, 2016 and November 28, 2016) to those who had not responded  Finally, we contacted all remaining nonrespondents by telephone starting December 5, 2016  The survey was available online until we reached a 100 percent response rate  To increase our understanding into how TAP was being implemented at installations and supplement our survey findings, we visited one Coast Guard installation and interviewed TAP managers from two additional installations  We selected the installations based on several factors, including the size of the installation, proximity to Department of Defense (DOD) installations, and diverse locations in the United States  (See table 1 ) At Coast Guard Base Elizabeth City in North Carolina, the installation we visited, we interviewed the TAP manager, uniformed career counselors, and senior installation leadership  During our interviews with TAP managers at all three installations, we asked about the extent to which Coast Guard servicemembers participate in TAP’s required and additional 2-day classes, including whether the servicemembers attended classes online or in a classroom setting, challenges to ensuring Coast Guard servicemembers participate in TAP, and the extent to which they monitor Coast Guard servicemembers’ participation in TAP  At Coast Guard Base Elizabeth City, we also interviewed 25 Coast Guard servicemembers (both officers and enlisted personnel) to get their perspective on how well TAP worked and any challenges they had participating  To help guide the interviews with the Coast Guard servicemembers, we asked them to complete a short questionnaire that asked about their experiences with the TAP program  We also interviewed TAP staff at Coast Guard headquarters to learn about TAP policy, monitoring efforts, and performance measures for the service overall  For example, we asked what policies and procedures guide installations’ TAP implementation; what performance measures the Coast Guard uses to monitor TAP; how performance results are reported and shared with different levels of Coast Guard leadership; and to what extent the Coast Guard uses results from TAP participant satisfaction assessments  We also asked whether the Coast Guard plans to shift to DOD’s new TAP-IT Enterprise System and how using the new system could affect its monitoring efforts in the future  In evaluating the Coast Guard’s performance measures, we focused on measures related to servicemembers’ transition experiences before leaving the military  We did not gather information on post-program evaluations and outcomes because they were determined to be outside the scope of this review  We reviewed DHS data on TAP participation for fiscal years 2012 to 2017  To assess the reliability of the Coast Guard’s TAP participation data, we interviewed agency officials knowledgeable about the data  We determined these data were not sufficiently reliable due to limitations with the Coast Guard’s data collection system  Specifically, the system lacks adequate controls to ensure TAP data are complete and accurate  We conducted this performance audit from February 2016 to April 2018 in accordance with generally accepted government auditing standards  Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives  We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives  In addition to the contact named above, Meeta Engle (Assistant Director), Amy MacDonald (Analyst-in-Charge), James Bennett, Holly Dye, David Forgosh, Ying Long, Jonathan McMurray, Jean McSween, Andrew Sherrill, Benjamin Sinoff, and Timothy Young, made significant contributions to this report  Also contributing to this report were Susan Aschoff, Jessie Battle, Ramona Burton, Melinda Cordero, Elizabeth Curda, Dawn Hoff, Ben Licht, Serena Lo, Sheila McCoy, Almeta Spencer, Christopher Schmitt, James Whitcomb, and Jill Yost  Transitioning Veterans: DOD Needs to Improve Performance Reporting and Monitoring for the Transition Assistance Program, GAO-18-23  Washington, D C : November, 8, 2017  Transitioning Veterans: Improvements Needed in DOD’s Performance Reporting and Monitoring of the Transition Assistance Program, GAO-18-225T  Washington, D C : November 8, 2017  Department of Defense: Transition Assistance Program (TAP) for Military Personnel, GAO-16-302R  Washington, D C : December 17, 2015  Veterans’ Employment: Need for Further Workshops Should Be Considered before Making Decisions on Their Future, GAO-15-518  Washington, D C : July 16, 2015  Military and Veteran Support: DOD and VA Programs That Address the Effects of Combat and Transition to Civilian Life, GAO-15-24  Washington, D C : November 7, 2014  Veterans Affairs: Better Understanding Needed to Enhance Services to Veterans Readjusting to Civilian Life, GAO-14-676  Washington, D C : September 10, 2014  Transitioning Veterans: Improved Oversight Needed to Enhance Implementation of Transition Assistance Program, GAO-14-144  Washington, D C : March 5, 2014  Military and Veterans’ Benefits: Enhanced Services Could Improve Transition Assistance for Reserves and National Guard, GAO-05-544  Washington, D C : May 20, 2005  Military and Veterans’ Benefits: Observations on the Transition Assistance Program, GAO-02-914T (July 18, 2002) 

ground_truth: The misuse of prescription opioid pain relievers and illicit opioids, such as heroin, has contributed to increases in overdose deaths. According to the most recent Centers for Disease Control and Prevention data, in 2015 over 52,000 people died of drug overdose deaths, and about 63 percent of them involved an opioid. For those who are addicted to or misuse opioids, MAT has been shown to be an effective treatment. GAO was asked to review HHS and other efforts related to MAT for opioid use disorders. This report (1) describes HHS's key efforts to expand access to MAT, (2) examines HHS's evaluation, if any, of its efforts to expand access to MAT, and (3) describes efforts by selected stakeholders (states, private health insurers, and national associations) to expand access to MAT. GAO gathered information from HHS officials as well as a non-generalizable selection of 15 stakeholders selected based on their MAT expansion activities, among other factors. GAO also assessed HHS's evaluation plans using internal control standards for defining objectives and evaluating results. In an effort to reduce the prevalence of opioid misuse and the fatalities associated with it, the Department of Health and Human Services (HHS) established a goal to expand access to medication-assisted treatment (MAT). MAT is an approach that combines behavioral therapy and the use of certain medications, such as methadone and buprenorphine. HHS has implemented five key efforts since 2015 that focus on expanding access to MAT for opioid use disorders—four grant programs that focus on expanding access to MAT in various settings (including rural primary care practices and health centers) and regulatory changes that expand treatment capacity by increasing patient limits for buprenorphine prescribers and allowing nurse practitioners and physician assistants to prescribe buprenorphine. Some of the grant awards were made in 2015, while others were made as recently as May 2017. (See figure.) As of August 2017, efforts under all the grant programs were ongoing. Grant recipients can use funding to undertake a range of activities, such as hiring and training providers and supporting treatments involving MAT. In addition, certain providers and grant recipients are required to develop plans for preventing MAT medications from being diverted for nonmedical purposes. HHS officials told GAO that as of August 2017, the department was in the process of finalizing its plans to evaluate its efforts to address the opioid epidemic. In September 2016, HHS awarded a contract to conduct the evaluation. HHS officials told GAO that they are still working with the contractor to finalize the evaluation approach and that it will focus on whether HHS's efforts to address the opioid epidemic have been implemented as intended. HHS officials said that in the future, HHS may also evaluate whether, or to what extent, its efforts have been effective in expanding access to MAT, in addition to evaluating implementation. While HHS has some of the information that could be used in a future evaluation of the effectiveness of its efforts to expand access to MAT, it has not adopted specific performance measures with targets specifying the magnitude of the increases HHS hopes to achieve through its efforts to expand access to MAT, and by when. For example, HHS has not established a long-term target specifying the percentage increase in the number of prescriptions for buprenorphine HHS would like to achieve, which would help to show whether efforts by HHS and others are resulting in a sufficient number of prescriptions for MAT medications. HHS has also not chosen a specific method of measuring treatment capacity or established targets associated with it, which would help determine whether a sufficient number of providers are becoming available to evaluate and treat patients who may benefit from MAT. Without specifying these performance measures and associated targets, HHS will not have an effective means to determine whether its efforts are helping to expand access to MAT or whether new approaches are needed. Gauging this progress is particularly important given the large gap identified nationwide between the total number of individuals who could benefit from MAT and the limited number who can currently access it based on provider availability. In addition, GAO also found that as of August 2017, HHS had not finalized its approach for its planned evaluation activities, including timeframes. Without timeframes for the evaluation's activities, HHS increases the risk that the evaluation will not be completed as expeditiously as possible. In addition to HHS efforts to expand access to MAT, officials from selected states, private health insurers, and national associations reported using several efforts to expand patients' access to MAT for opioid use disorders. For example, several stakeholders provided GAO with the following examples of their efforts: States. State health officials from all five selected states have implemented or are planning approaches that focus on integrating the use of MAT into primary care, such as by providing services for centralized intake and initial management of patients or through telehealth that connects patients in rural areas with addiction specialists in a different location. Private health insurers. Three private health insurers reported removing prior authorization requirements for MAT medications so patients can avoid a waiting period before receiving the medications. National associations. Officials told GAO that they are conducting outreach and training for their members and developing tools and resource guides. For example, one association developed a road map with strategies that state policymakers can use to address the opioid epidemic, including strategies for reducing the stigma associated with MAT through educating the public and potential providers. GAO recommends that HHS take two actions: (1) establish performance measures with targets related to expanding access to MAT, and (2) establish timeframes for its evaluation of its efforts to expand access to MAT. HHS concurred with both recommendations.

prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 2.

Report 1: Health care practitioners prescribe opioid medications to treat pain and sometimes for other health problems, such as severe coughing  Opioid medications are available as immediate or extended release and in different forms, such as a pill, liquid, or a patch worn on the skin  Opioids slow down some processes of the body, such as breathing and heartbeat, by binding with certain receptors in the body  Over time, the body becomes tolerant to opioids, which means that larger doses of opioid medications are needed to achieve the same effect  People may use opioids in a manner other than as prescribed—that is, they can be misused  Because opioids are highly addictive substances, they can pose serious risks when they are misused, which can lead to addiction and death  Symptoms of an opioid use disorder include a strong desire for opioids, the inability to control or reduce use, and continued use despite interference with major obligations or social functioning  Another concern associated with prescribed opioids is the potential for diversion for illegal purposes, such as nonmedical use or financial gain  Research has shown that MAT—which combines behavioral therapy and the use of certain medications (methadone, buprenorphine, and naltrexone)—can be more effective in reducing opioid use and increasing retention (i e , reducing dropouts) compared to abstinence based treatment—that is when patients are treated without medication  Three medications are currently approved by FDA for use in MAT for opioid use disorders—methadone, buprenorphine, and naltrexone  Methadone: Methadone is a full opioid agonist, meaning it binds to and activates opioid receptors to help prevent withdrawal symptoms and reduce drug cravings  It has a long history of use for the treatment of opioid dependence in adults  Methadone suppresses withdrawal symptoms during detoxification therapy, which involves stabilizing patients who are addicted to opioids by withdrawing them in a controlled manner  Methadone also controls the craving for opioids during maintenance therapy, which is ongoing therapy meant to prevent relapse and increase treatment retention  Methadone can be administered to patients as an oral solution or in tablet form  Buprenorphine: Buprenorphine is a partial opioid agonist, meaning it binds to opioid receptors and activates them, but not to the same degree as full opioid agonists  It reduces or eliminates opioid withdrawal symptoms, including drug cravings  It can be used for detoxification treatment and maintenance therapy  It is available for MAT for opioid use disorder in tablet form for sublingual (under the tongue) administration, in film form for sublingual or buccal (inside the cheek) administration, and as a subdermal (under the skin) implant  Naltrexone: Naltrexone is an opioid antagonist, meaning it binds to opioid receptors but does not activate them  It is used for relapse prevention following complete detoxification from opioids  Naltrexone prevents opioid drugs from binding to and activating opioid receptors, thus blocking the euphoria the user would normally feel  It also results in withdrawal symptoms if recent opioid use has occurred  It can be taken daily in an oral tablet form or as a once-monthly injection given in a doctor’s office  Two of the three medications used to treat opioid use disorders— methadone and buprenorphine—are drugs that carry a potential for misuse  Under the Controlled Substances Act (CSA), treatment involving these medications can take place in certain authorized settings: as part of federally regulated OTPs or in other settings, such as a physician’s office, within certain restrictions  OTPs  OTPs provide MAT, including methadone and buprenorphine, for people diagnosed with an opioid use disorder  Methadone may generally only be administered or dispensed within an OTP, as prescriptions for methadone cannot be issued when used for opioid use disorder treatment  Buprenorphine may be administered or dispensed within an OTP, or may also be prescribed by a qualifying practitioner who has received a waiver from SAMHSA  Naltrexone is not a controlled substance and can be used in OTPs and other settings  Office-Based and Other Settings  Under a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver, practitioners may prescribe buprenorphine to up to 30 patients in the first year of their waiver, 100 patients in the second year, and up to 275 patients in the third year  Practitioners at the 275-patient level must meet additional qualifications and requirements  Naltrexone does not have similar restrictions  HHS has implemented five key efforts from 2015 through August 2017 that focus on expanding access to MAT for opioid use disorders  Four of these are grant programs, including programs focused on health centers or primary care practices in rural areas  Targeted Capacity Expansion: Medication Assisted Treatment – Prescription Drug and Opioid Addiction (MAT-PDOA)  This grant program is administered by SAMHSA and provides funding to states to increase their capacity to provide MAT and recovery support services to individuals with opioid use disorders  Grant recipients are expected to identify a minimum of two high-risk communities within the state and partner with local government or community- based organizations to address the MAT-related treatment needs in these communities  Among other things, recipients are to use outreach and other engagement activities to increase participation in and access to MAT for diverse populations at risk for opioid use disorders  In August 2015, SAMHSA awarded 3-year grants to 11 states, under which each of the states will receive up to $1 million in each grant year  In September 2016, SAMHSA awarded 11 additional 3-year grants to other states  Total funding is expected to be up to $66 million for all 22 grants  SAMHSA announced the availability of up to 5 additional 3-year grants for fiscal year 2017  Applications for these grants of up to $2 million per year were due in July 2017 and as of August 2017 they had not been awarded  Substance Abuse Service Expansion Supplement to Health Centers  This grant program is administered by HRSA and provides funds for existing health centers to improve and expand their delivery of substance abuse services, including services with a specific focus on MAT for opioid use disorders in underserved populations  Health centers that receive these grants are required to increase the number of patients with health center-funded access to MAT for opioid use or for other substance abuse disorders treatment by adding at least one full-time substance abuse provider and supporting new or enhanced existing substance abuse services  HRSA awarded 2-year grants in March 2016 to 271 health centers  According to HRSA documents, total funding could be up to $200 million for all grants over 2 years  HRSA announced the availability of another set of grants to health centers for fiscal year 2017  Applications for these grants were due in July 2017, and as of August 2017 they had not been awarded  Increasing Access to Medication-Assisted Treatment in Rural Primary Care Practices  This grant program is administered by AHRQ and funds demonstration research projects that aim to expand access to MAT for opioid use disorders in primary care practices in rural areas of the United States  Grant recipients are expected to recruit and engage primary care providers and their practices, provide training, and support physicians and their practices in initiating treatment  The program also identifies and tests strategies for overcoming the challenges associated with implementing MAT in primary care settings and creates training and other resources for implementing MAT  AHRQ awarded these 3-year grants of up to $1 million per year to four recipients—the recipients are teams of state health departments, academic health centers, local community organizations, physicians, and others—with project start dates of September 30, 2016  According to AHRQ documents, total funding is expected to be up to $12 million for the four grants over 3 years  State Targeted Response to the Opioid Crisis Grants (Opioid STR)  This grant program is administered by SAMHSA and provides funding to states and others to increase access to treatment services for opioid use disorders, including MAT; reduce unmet treatment needs; and reduce opioid overdose deaths  Grant recipients are expected to implement or expand access to evidence-based practices, particularly the use of MAT, and to report on the number of people who receive opioid use disorder treatment, the number of providers implementing MAT, and the number of providers trained to use MAT  SAMHSA awarded 2-year grants starting in May 2017 to 50 states, the District of Columbia, four U S  territories and the free associated states of Micronesia and Palau  According to SAMHSA documents, total funding could be up to $970 million for all grants over 2 years  Figure 1 displays the implementation timeframes, the number of grants, and funding levels for the four HHS grant programs related to MAT  As the figure shows, some of these awards were made in fiscal year 2015, while others were made as recently as May 2017  As of August 2017, these efforts were ongoing  In addition to these four grant programs, HHS’s fifth key effort increases treatment capacity by expanding the waivers that practitioners may receive to prescribe buprenorphine  Specifically, SAMHSA issued a regulation that became effective August 8, 2016 increasing the number of patients that eligible practitioners can treat with buprenorphine outside of an OTP (e g , in an office-based setting)  Previously, qualified practitioners could request approval to treat up to 30 patients at a time, and after 1 year the limit could increase to 100 patients at a time upon SAMHSA approval  The new regulation expanded access to MAT by allowing eligible practitioners who have had waivers to prescribe buprenorphine to 100 patients for at least 1 year to request approval to treat up to 275 patients thereafter  Similarly, SAMHSA has implemented provisions of the Comprehensive Addiction and Recovery Act of 2016 (CARA) that expanded the types of practitioners who can receive a waiver to prescribe buprenorphine in an office-based setting to include qualifying nurse practitioners and physician assistants  CARA generally requires that these nurse practitioners and physician assistants complete 24 hours of training to be eligible for a waiver  According to HHS documents, as of early 2017, nurse practitioners and physician assistants who have completed this training could request a waiver from SAMHSA to treat up to 30 patients at a time  In addition to its five key efforts focused specifically on expanding access to MAT for opioid use disorders, HHS has other efforts with broader focuses, such as treating multiple types of substance abuse  While these efforts are not specifically focused on expanding access to MAT for opioid use disorders, they may result in expanded access to MAT  For example, CMS has approved section 1115 Medicaid demonstration projects to allow states to undertake comprehensive reforms of their delivery of substance abuse services, including provisions to enhance the use of MAT for opioid use disorders  In July 2015, CMS issued a state Medicaid Director letter informing states that they may seek approval of section 1115 demonstrations to undertake comprehensive substance use service reforms  According to CMS, all participating states are using the demonstration authority to develop a full continuum of care for individuals with substance abuse disorders, including coverage of short-term residential treatment services not otherwise covered by Medicaid  In addition, FDA has programs to help expedite development and to provide for faster review of marketing applications for certain drugs  According to FDA, it has conducted expedited reviews of Suboxone (buprenorphine and naloxone sublingual film), Vivitrol (extended release naltrexone injection) and Probuphine (buprenorphine subdermal implant)  According to some federal officials and other stakeholders that we interviewed, as part of efforts to expand access to MAT for opioid use disorder, steps are being taken to prevent the possibility that the MAT medications could, in some cases, be diverted for illicit use, misuse, or for purposes not intended by a prescriber  For example, OTPs and practitioners who request and receive a waiver to prescribe buprenorphine to treat up to 275 patients outside of an OTP setting are required under federal regulations to maintain a diversion control plan  In addition, the MAT-PDOA grant program explicitly requires grant recipients to implement a diversion control plan, though the other grant programs do not have similar additional requirements  (See appendix I for an overview of the diversion control plan requirements for OTPs and the practitioners who prescribe buprenorphine outside of an OTP ) The 2016 Surgeon General’s report on Alcohol, Drugs, and Health noted that decades of research have shown that the benefits of MAT greatly outweigh the risks associated with diversion, and that withholding these medications greatly increases the risk of relapse to illicit opioid use and overdose death  HHS officials told us that as of August 2017, the department is in the process of finalizing its approach for evaluating the implementation of its agencies’ collective efforts to address the opioid epidemic that were undertaken as part of the HHS Opioid Initiative and will continue under the new administration’s Opioid Strategy  HHS officials provided a draft of the evaluation’s schedule  According to the officials, the evaluation will include, but not be limited to, efforts to expand access to MAT  In September 2016, HHS awarded a 2-year contract to Research Triangle Institute International (RTI) to evaluate HHS agencies’ collective efforts  HHS officials told us that they are still working with RTI to finalize the evaluation approach given new leadership priorities  Specifically, in April 2017, the new Secretary of HHS announced a revised strategy for addressing the opioid epidemic that will continue to address access to MAT for opioid use disorders but also include additional priority areas  According to HHS officials, to be responsive to the new priorities, the evaluation will focus initially on whether HHS’s efforts have been implemented as intended, and officials expect the evaluation to also provide information on any challenges HHS has faced in implementing these efforts  According to HHS officials, while the evaluation of MAT expansion efforts will use information from several sources, they have not yet determined exactly which information will be used or how it will be used  This information may include, for example, results from a separate, planned evaluation of one of the grant programs, Opioid STR, as well as other information HHS agencies collect as part of their ongoing monitoring efforts for each of their individual MAT grant programs  While the reporting requirements vary across the four MAT grant programs, the grantees provide HHS with information related to expanding access to MAT  Specifically, Targeted Capacity Expansion: Medication Assisted Treatment – Prescription Drug and Opioid Addiction (MAT-PDOA): Every 6 months, grant recipients are expected to submit progress reports to SAMHSA on the planned and actual number of patients treated, as well as information on other performance measures  Increasing Access to Medication-Assisted Treatment in Rural Primary Care Practices: Grant recipients are expected to submit quarterly progress reports to AHRQ with various information, such as information on the number of physicians who have been certified to prescribe buprenorphine and the number of primary care practices successfully initiating the delivery of MAT services as a result of the grant project  Substance Abuse Service Expansion Supplement to Health Centers: Health centers that received these grants were expected to submit quarterly progress reports to HRSA through the second quarter of 2017 on the number of physicians who have obtained a DATA 2000 waiver and the number of patients who received MAT from these physicians  Health centers must now report these data elements in their annual performance reporting along with information on the number of certified nurse practitioners and physician assistants who have received a DATA 2000 waiver  State Targeted Response to the Opioid Crisis Grants (Opioid STR): Every 6 months, grant recipients are expected to submit progress reports to SAMHSA on the number of individuals who receive opioid use disorder treatment, the number who receive opioid use disorder recovery services, and the number of providers implementing MAT, among other measures  While HHS’s evaluation will focus on whether HHS’s efforts have been implemented as intended, officials told us that in the future an evaluation may also focus on the effectiveness of these efforts, including the effectiveness of efforts to expand access to MAT  Doing so would be consistent with federal standards for internal control, which call for agencies to evaluate results  HHS has some of the information that could be used in a future evaluation of the effectiveness of its efforts to expand access to MAT  In particular, an HHS document describing the department’s fiscal year 2016 – 2017 goals identifies expanding MAT access as an important strategy for the success of HHS’s longer-term goal of reducing opioid use disorders and opioid overdoses  In addition, HHS has identified three potential ways to measure access to MAT: the number of prescriptions for MAT medications, the treatment capacity of practitioners who are authorized to prescribe buprenorphine for opioid use disorders through a DATA 2000 waiver, and the treatment capacity of OTPs certified to administer methadone and other medications  In addition, HHS has data that could be useful for tracking progress in these areas (see table 1)  However, HHS has not adopted specific performance measures with targets specifying the magnitude of the increases HHS hopes to achieve through its efforts to expand access to MAT, and by when  For example, HHS has not established a long-term target specifying the percentage increase in the number of prescriptions for buprenorphine HHS would like to achieve, which would help to show whether efforts by HHS and others are resulting in sufficient progress in increasing prescriptions for this MAT medication  HHS has also not chosen a specific method of measuring treatment capacity or established targets associated with it, which would help to show whether a sufficient number of providers are becoming available to evaluate and treat patients who may benefit from MAT  Without specifying these performance measures and associated targets, HHS will not have an effective means to determine whether its efforts are helping to expand access to MAT  The lack of such performance measures with associated targets is inconsistent with federal internal control standards that specify that management should define objectives and evaluate results  According to these standards, using performance information such as performance measures can help agencies monitor results and determine progress in meeting program goals  In the context of HHS’s efforts to expand access to MAT, establishing appropriate performance measures with associated targets would allow HHS to determine whether its efforts are making sufficient progress or whether they need to be improved  Gauging this progress is particularly important, given the large nationwide MAT treatment gap identified in 2015 between the total number of individuals who could benefit from MAT and the limited number who can access it based on provider availability  This gap was estimated at nearly 1 million people as of 2012, and according to HHS officials and other stakeholders, lack of providers continues to be a challenge  Until HHS establishes performance measures with associated targets for the factors related to access to MAT, the department will be unable to evaluate its progress expanding access to MAT for opioid use disorders  In addition, as of August 2017, HHS has not finalized its approach for the planned evaluation activities, including timeframes  ASPE officials said that timeframes for a finalized evaluation approach had not been established because they were still working with RTI to finalize the evaluation approach given the new leadership priorities  When we spoke with the officials, they provided us with a draft evaluation schedule that covered the contract period ending September 2018  As of October 2017, HHS had not provided a finalized evaluation approach or schedule  Federal internal controls call for management to establish and operate monitoring activities and evaluate results  Without an implementation timeframe for the evaluation’s activities, HHS increases the risk that its evaluation of its agencies’ efforts will not be completed as expeditiously as possible, including an evaluation of HHS’s efforts to expand access to MAT  Officials from selected state health departments and behavioral health agencies, private health insurers, and national associations reported using several different efforts to help expand patients’ access to MAT for opioid use disorders  All of the stakeholders we interviewed reported conducting outreach efforts to communicate information about the importance of MAT and how to access it, or providing training to educate providers on prescribing MAT medications  Efforts by states  State health officials we spoke to described several planned or ongoing efforts to expand access to MAT, some of which are supported by federal funding, including federal grant programs  Officials from all five selected states told us that they are offering outreach to and training for providers to help expand access to MAT  For example, several state officials told us that they are promoting training to (1) encourage physicians to obtain authorization (DATA 2000 waivers) to prescribe buprenorphine and (2) encourage physicians with waivers to treat patients up to their patient limit or to request a higher patient limit  According to the stakeholders, all five selected states have implemented or are planning to implement a health care delivery model or approach that will expand access to MAT  Specifically, these models or approaches focus on integrating the use of MAT into primary care settings  For example, health officials from three states described use of a hub-and-spoke model  This model generally involves centralized intake and initial management of patients at a “hub” (e g , an OTP) and then connecting these patients to community providers at “spokes” (e g , primary care clinics) for ongoing care, with ongoing support provided by the hub as needed  Additionally, officials from two states described offering remote MAT-related consultations through telehealth that connects patients in rural areas with addiction specialists  According to a 2017 Healthcare Fraud Prevention and Partnership whitepaper, telehealth expands the reach of the addiction professional workforce and the existing pool of MAT providers, and it supports remote forms of behavioral therapy to make trained professionals more accessible to those in underserved or isolated communities  Officials from three states described focusing their MAT expansion efforts in various settings, such as in the criminal justice setting and emergency room departments  State health officials from four of the five states told us that programs in their states are using peer specialists (individuals who have successfully recovered from substance abuse disorders) in emergency rooms and other settings to engage with addicted patients and refer them to addiction specialists or behavioral health counselors  Officials from the selected states said that some of these and other efforts are funded through federal sources, such as MAT expansion grants awarded by SAMHSA, or with state funds to the extent they are available  Efforts by private health insurers  Officials from private health insurers reported that they are expanding access to MAT through outreach or training for providers and through the following three efforts: Eliminating the need for prior authorization to prescribe MAT medications  Officials from three insurers reported removing prior authorization requirements for MAT medications, thereby making it easier for patients to access needed MAT medications more readily, rather than undergoing a waiting period for approval to receive the medications  Other private health insurers told us that they continue to require prior authorization, intended for safety reasons and to reduce drug misuse, and officials from one insurer told us that they will allow a patient to access a limited amount of MAT medications for a period of 24 to 72 hours while making a determination about the appropriate treatment services for the patient  Modifying health benefit coverage  Officials from one private health insurance plan told us that the company is redesigning the benefit coverage for methadone and has removed member copays  This effort is intended to make MAT medications more affordable and allow members who are not able to use buprenorphine to have an alternative, such as methadone, that is not cost-prohibitive  Incentivizing providers and health insurance plan members to use MAT  Officials from four private health insurance plans described plans to offer incentives to providers or patients to use MAT  For example, officials from three health plans stated that they are offering alternative payment models or paying higher rates to providers that offer MAT, and another private health insurer is offering incentives to its members who are enrolled in behavioral health programs that provide access to MAT  Efforts by national associations  Officials we interviewed from the national associations—including the American Society of Addiction Medicine, the National Governors Association, and the Association of State and Territorial Health Officials—told us that they are helping to expand access to MAT through outreach and training for their members and by developing tools and resource guides for their members  An official from one association told us that it shares federal grant announcements, including those that are focused on expanding access to MAT, with its members  Officials from another association said it provides training to providers on how to appropriately prescribe MAT medications  In addition, officials from one association told us that they developed an opioid-related road map that identifies examples of strategies—including MAT—that state policymakers can use in their ongoing efforts to address the opioid epidemic  Examples of strategies include reducing the stigma associated with MAT through educating the public and potential providers  Another strategy in the road map is changing payment policies to expand access to MAT services, such as ensuring that Medicaid and other state health programs adequately cover all MAT medications and behavioral interventions and encouraging or requiring commercial health plans to adopt similar policies  HHS funds grant programs and has taken other steps to expand access to MAT, which has been shown to be effective in reducing the prevalence of opioid use disorders and with them, the likelihood of drug overdoses  HHS’s Opioid Initiative began in 2015, and the grants that support it are ongoing, so it is likely too early to determine how effective HHS’s efforts have been in expanding access to MAT and in meeting HHS’s other priorities related to addressing the opioid epidemic  According to HHS, access to MAT can be measured in terms of the number of prescriptions for MAT and by the treatment capacities of OTPs and practitioners who are authorized to prescribe buprenorphine  Our review suggests, however, that HHS may not be ready to perform this evaluation  While HHS told us that it may evaluate the effectiveness of its efforts in the future, the department has not established performance measures with targets that would specify the results that HHS hopes to achieve through its efforts, and by when  Furthermore, HHS has not established timeframes for the activities that will make up its planned evaluation of whether HHS’s efforts have been implemented as intended  Without performance measures with targets and evaluation timeframes, HHS increases the risk that the evaluation will not be completed in a timely manner or that HHS will not know whether its MAT- related efforts are successful or whether new approaches are needed  The evaluation is particularly important, given the hundreds of millions of dollars HHS has invested in its MAT-related grant programs  We are making the following two recommendations to HHS  The Assistant Secretary for Planning and Evaluation should establish performance measures with targets related to expanding access to MAT for opioid use disorders  (Recommendation 1) The Assistant Secretary for Planning and Evaluation should establish timeframes in its evaluation approach that specify when its evaluation of efforts to expand access to MAT will be implemented and completed  (Recommendation 2) We provided a draft of this report to HHS for review, and HHS provided written comments, which are reprinted in appendix II  HHS also provided technical comments, which we incorporated as appropriate  In its written comments, HHS concurred with both of our recommendations  Specifically, for our first recommendation to establish performance measures with targets related to expanding access to MAT for opioid use disorders, HHS stated that developing such measures is appropriate and that the department will continue to work to develop robust performance measures, including measures related to MAT, as part of its overall Opioid Strategy, which includes the department’s most recent efforts to address the opioid epidemic  For our second recommendation to establish timeframes in its evaluation approach that specify when its evaluation of efforts to expand access to MAT will be implemented and completed, HHS agreed that timeframes are important to any evaluation  HHS noted that its evaluation is being conducted under a 2-year contract that is scheduled to end in September 2018  HHS has also provided us with a draft evaluation schedule  We clarified in our report, however, that HHS has not yet provided a finalized approach for the planned evaluation or a finalized schedule establishing timeframes for the activities that will make up the evaluation  Until it finalizes its evaluation approach and establishes related timeframes, HHS increases the risk that it will not complete its planned evaluation by September 2018  We are sending copies of this report to the HHS, and appropriate congressional committees  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff have questions about this report, please contact me at (202) 512-7114 or curdae@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  Major contributors to this report are listed in appendix III  According to the Department of Health and Human Services, a diversion control plan is a set of documented procedures intended to reduce the possibility that controlled substances will be transferred or used illicitly  Opioid treatment programs (OTPs) and practitioners who prescribe buprenorphine at the highest patient level through a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver are required to have these plans  OTPs are programs that may administer or dispense medication- assisted treatment (MAT) for people diagnosed with an opioid use disorder, including the use of methadone and buprenorphine  In addition, under a DATA 2000 waiver, practitioners may prescribe buprenorphine for patients, up to a 30-, 100-, or 275 patient limit  An OTP must maintain a current diversion control plan that contains specific measures to reduce the possibility of diversion of controlled substances from legitimate treatment use  Per federal guidelines, the goal of the diversion control plan is to reduce the scope and significance of diversion and its impact on communities  The guidelines state that each OTP’s diversion control plan should make every effort to balance diversion control against the therapeutic needs of the individual patient  They also state that diversion control plans should address at least four general areas of concern: program environment, dosing and take-home medication, prevention of multiple program enrollment, and prescription medication misuse  The guidelines include details about each of these areas: Program environment: Diversion in the program environment can be deterred and detected by regular surveillance and the monitoring of areas in and around the program, where opportunities for diversion may exist  A visible human presence at a program’s location gives community members the opportunity to approach staff with concerns and communicates the program’s commitment to assuring a safe environment and a positive impact on the surrounding community  Dosing and take-home medication: In the area of dosing and take- home medication, diversion control encompasses careful control of inventory, attentive patient dosing, and close supervision of take- home medication  Observing a patient take his or her dose and having each of them drink and speak after dosing are fundamental components of diversion control  Take-home dosing should be provided with careful attention to regulatory compliance and the therapeutic benefit and safety these regulations are meant to promote  Prevention of multiple program enrollment: Reasonable measures should be taken to prevent patients from enrolling in treatment provided by more than one clinic or individual practitioner  An OTP, after obtaining patient consent, may contact other OTPs within a reasonable geographic distance (100 miles) to verify that a patient is not enrolled in another OTP  Misuse of prescription medication: The misuse of prescription medication has become an area of great concern nationally and impacts diversion control planning at OTPs  All OTP physicians and other healthcare providers, as permitted, should register to use their respective state’s prescription drug monitoring program (PDMP) and query it for each newly admitted patient prior to initiating dosing  The PDMP should be checked periodically (for example, quarterly) through the course of each individual’s treatment and, in particular, before ordering take-home doses as well as at other important clinical decision points  SAMHSA’s best-practice guidelines for using buprenorphine for treating opioid use disorders include multiple references to diversion, including monitoring for diversion, storage of this medication to minimize diversion, and use of formulations that may be less likely to be diverted  Specifically, the best practices state that, when possible, practitioners should use the combination buprenorphine/naloxone product, which increases safety and decreases the likelihood of diversion and misuse  Further, physicians who request and receive a waiver to prescribe buprenorphine to treat up to 275 patients outside of an OTP are required to have a diversion control plan  According to an HHS official, as of July 13, 2017, roughly 3,330 of the over 39,000 practitioners with a waiver had a 275-patient limit waiver  The majority of these practitioners, just over 27,000, have a 30-patient limit  According to SAMHSA guidance, the diversion plan should contain specific measures to reduce the possibility of diversion of buprenorphine from legitimate treatment use and should assign specific responsibilities of the medical and administrative staff of the practice setting for carrying out these measures  Further, the guidance states that the plan should address how: the environment at the practice setting can prevent onsite diversion; to prevent diversion with regard to dosing and take-home medication; and to prevent patients from receiving a prescription from more than one practitioner and later diverting some of the prescribed medication  Elizabeth H  Curda, Director, (202) 512-7114 or curdae@gao gov  In addition to the contact name above, Will Simerl, Assistant Director; Natalie Herzog, Analyst-in-Charge; La Sherri Bush; and Emily Wilson made key contributions to this report  Also contributing were Muriel Brown, Krister Friday, Sandra George, and Christina Ritchie 


Report 2:  Developing international military capacity  U S  officials told us that UN peacekeeping operations provide an indirect benefit of helping to professionalize the military units from many developing countries that contribute troops to the UN  We have previously reported that building military capacity of foreign partners to address security-related threats is an important goal of U S  national security strategy and foreign policy  According to U S  and UN officials, the relative strengths of U S  peacekeeping operations would be faster deployment and superior command and control, logistics, intelligence, and counterterrorism capabilities  Deployment speed  State, DOD, and UN officials highlighted the United States’ ability to deploy troops and police to peacekeeping operations more quickly than the UN  Unlike the U S  military, which can draw from a ready pool of military personnel, the UN must seek troops from UN member states, which takes time  UN officials told us that the UN faces a shortage of both troops and UN police, which slows deployment  Further, a 2015 report by the UN High-level Panel on Peacekeeping stated that the UN “has struggled to get sufficient forces on the ground quickly enough and relies on under-resourced uniformed capabilities ” The report also stated that aviation, medical, and engineering specialists, among others, are difficult to mobilize in advance of infantry units  Command and control  State, DOD, and UN officials told us that U S  operations would enable the U S  military to have direct command and control, whereas UN operations, which are inherently multinational, face challenges with command and control over troops from several different countries  The UN High-level Panel report noted that UN peacekeeping operations’ weak command and control is a well-known constraint that limits the type of operations the UN can undertake  Logistics support  U S  and UN officials told us that U S  operations have superior logistics systems  U S  procurement likely would be faster than UN procurement, which lacks a standing supply chain and, therefore, relies on third-party vendors, according to UN officials  In addition, the UN High Level Panel report stated that UN peacekeeping operations’ logistics systems and structures in the field are under severe strain, which can limit the mobility of these operations  Intelligence capability  U S  and UN officials agreed that U S  operations would involve superior intelligence capability  The UN only recently established an intelligence policy—in May 2017—having recognized that some peacekeeping operations had been deployed in fragile political and security environments with asymmetrical and complex threats  However, UN officials acknowledged that the scope of UN intelligence capability remains limited  Counterterrorism capability  DOD officials told us that a U S  peacekeeping operation would have the capability to include a counterterrorism component and would not be constrained in the use of force, if needed, in response to terrorist threats  UN peacekeeping operations, on the other hand, lack the capabilities and specialized military preparation to engage in counterterrorism operations, according to the UN High-level Panel report  The UN report stated that counterterrorism should be undertaken by the host government, a capable regional force, or an ad hoc coalition authorized by the UN Security Council  According to the UN report, UN peacekeeping operations may engage in proactive and preemptive use of force to protect civilians and UN personnel from threats; however, offensive force to degrade, neutralize or defeat an opponent is a fundamentally different type of posture that should be authorized by the Security Council only under limited and exceptional circumstances  We provided a draft of this report to DOD, State, and the UN for review and comment  DOD provided a letter, reproduced in appendix II, which stated that it had no comments  State did not provide comments  The UN provided technical comments, which we incorporated into our report as appropriate  We are sending copies of this report to the appropriate congressional committees, the Secretaries of Defense and State, and the Secretary- General of the United Nations  In addition, the report is available at no charge on the GAO website at http://www gao gov  If you or your staff have any questions about this report, please contact me at (202) 512-9601 or melitot@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 significant contributions to this report are listed in appendix III  The objectives of this report were to (1) compare the reported costs of a specific United Nations (UN) peacekeeping operation to the estimated costs of a hypothetical, comparable operation implemented by the United States; (2) identify factors that affect cost differences; and (3) identify stakeholder views on the relative strengths of UN and U S  peacekeeping operations  To compare the reported costs of a specific UN peacekeeping operation to the estimated costs of a hypothetical, comparable operation implemented by the United States, we selected the UN Multidimensional Integrated Stabilization Mission in the Central African Republic (MINUSCA) as a case study  We compared the reported UN expenditures for MINUSCA, which included both military and civilian components, with estimated costs for a hypothetical U S  operation with a similar level of military and civilian personnel  Our comparison covers a total of 3 years and 3 months—from MINUSCA’s establishment in April 2014 through June 30, 2017, the end of UN fiscal year 2017  We selected MINUSCA because it is in sub-Saharan Africa, where most UN peacekeeping operations established since 2003 have taken place, and has a typical scope and budget compared to other UN peacekeeping operations in sub-Saharan Africa, according to U S  and UN officials  In addition, MINUSCA is one of the most recent UN peacekeeping operations; thus, initial expenditures for the operation are relatively current  Because the results of our cost comparison are based on a single case study, they cannot be generalized to all UN peacekeeping operations  To determine the UN’s costs for MINUSCA, we analyzed UN budget and expenditure data covering the initial start-up period (April 2014 to June 2014) and the first 3 UN fiscal years (July 1, 2014 to June 30, 2017)  We spoke with officials of the UN Departments of Peacekeeping Operations, Field Support, and Management at UN Headquarters in New York, New York, to better understand the characteristics of MINUSCA and the different costs affecting MINUSCA’s budget and expenditures  We assessed UN expenditure data through discussions with cognizant UN officials and a review of external audits of UN budgetary information and found them sufficiently reliable for our purposes  We also analyzed data on U S  contributions to UN peacekeeping operations for fiscal years 2014 through 2017 from the Department of State’s (State) Bureau of International Organization Affairs to determine total U S  contributions to MINUSCA, and UN peacekeeping operations overall  To estimate the costs of a hypothetical, comparable operation implemented by the United States, we developed a hypothetical scenario for a U S  operation based on the MINUSCA budget and supporting documents, assuming deployment of the same number of military, civilian, and police personnel in the Central African Republic (CAR) over the same time period (April 2014 through June 2017)  To estimate the military portion of the operation, we interviewed Department of Defense (DOD) officials and staff at the Institute for Defense Analyses (IDA), a DOD-sponsored non-profit corporation involved in developing cost estimates for U S  contingency operations  The Office of the Undersecretary of Defense-Comptroller and IDA generated a cost estimate for the military components included in the hypothetical operation using the Contingency Operations Support Tool (cost estimating tool)  DOD uses this tool to develop cost estimates for all military contingency operations  The cost estimate included only the incremental costs of the operation—those directly attributable to the operation that would not be incurred if the operation did not take place  For example, the estimate produced by the cost estimating tool did not include the direct salaries of active duty personnel as those costs would be incurred by the United States regardless of a possible decision to undertake the hypothetical operation  We assessed the cost estimating tool’s applicability to developing a hypothetical cost estimate for the purposes of this report through discussions with DOD and IDA officials, and compared the tool to the accurate and comprehensive characteristics of a high-quality cost estimate, as described in the GAO Cost Estimating and Assessment Guide  While we found the DOD cost estimating tool generated a sufficiently reliable cost estimate for a hypothetical U S  peacekeeping operation, we did not assess the overall reliability of the tool or its capability to generate accurate or comprehensive estimates for future U S  operations  To generate our estimate of U S  military costs using the DOD’s estimating tool, we used UN military deployment numbers as a baseline for the scale of a hypothetical, comparable U S  peacekeeping operation, while using unit sizes and rotations in deployment that were considered appropriate for the U S  military, according to DOD and IDA officials  We based the hypothetical U S  operation, and hence the cost estimate, on the following assumptions, which correspond approximately with MINUSCA’s actual UN personnel deployments: Theater of operation: Central African Republic (CAR) Type of operation: military contingency Operation time frame: April 10, 2014 through June 30, 2017 Military contingents: as of June 30, 2017, 11,495 total personnel Infantry: 10 units of 630-785 personnel per unit, approximately 90 percent active duty / 10 percent reserves Communication / signals: 1 unit, 124 personnel per unit Engineering: 4 units, 200 personnel per unit Military police: 1 unit, 120 personnel per unit Formed police units (military police): 12 units, 140 personnel per Hospital / medical: 1 level III hospital, 248 beds, 495 personnel Helicopter units: 2 UH-60 C3 units, 1 MH-60M Assault attack helicopter unit, 100 personnel per unit Quick reaction force: 1 unit, 160 personnel per unit Special forces: 1 tactical civilian affairs unit, 1 Marine special operations intelligence unit, 160 personnel per unit Unmanned aerial vehicle: 1 unit, 84 personnel Transportation: 1 heavy transport unit, 120 personnel per unit Operational tempo: 1 0 for all phases of operation and units, except aviation units (set at 1 5) Deployment schedule and phasing: phased deployment, including 14 days for predeployment (e g , training), 5 days for deployment, 180 days for active duty unit sustainment and 270 days for reserve unit sustainment, 5 days for redeployment, and 0 days for reconstitution Housing: contractor-provided semi-permanent housing Transportation: personnel and equipment transported by airlift from the United States (primarily Fort Hood, Texas), material (such as water, food, and other consumables) transported by airlift from Italy We obtained input on the operational design for the military portion of the cost estimate from DOD officials in the Joint Chiefs of Staff, the Office of the Undersecretary of Defense-Policy, and the Office of the Undersecretary of Defense-Comptroller, and IDA officials  However, the military portions of the scenario and their corresponding cost estimate have some limitations  As a result of rounding for some units, U S  military personnel numbers do not exactly match the MINUSCA deployment levels  In addition, based on input from DOD officials, we attempted to select military units that would provide an essential function per U S  common practices while keeping the overall personnel deployment level as close as possible to MINUSCA’s deployment level  An actual U S  military plan may differ significantly from the UN plan as a result of differences between U S  and UN military operations, structure, doctrine, and circumstances at the time of the operation  To estimate U S  civilian costs, we matched the number of U S  civilian police and personnel to the number serving in MINUSCA  We then estimated the costs of deploying these U S  civilian personnel in CAR for the same time period as MINUSCA  We did not attempt to determine how the U S  government would actually implement civilian components of a peacekeeping operation in CAR  To estimate U S  civilian police costs, we met with State’s Bureau of International Narcotics and Law Enforcement Affairs (INL) to identify State’s costs for civilian police contractors providing police training and technical assistance in sub-Saharan Africa  Based on INL’s input we assumed that the base salary of civilian police would be grade 13, step 5 on the Office of Personnel Management’s general schedule salary tables for federal employees  In addition to the average base salary, we identified other costs—with input from INL—including, among others, personal equipment, travel from the United States, and State’s published allowances specific to CAR for local cost of living, post hardship differential, danger pay, and living quarters  We applied the average cost per officer to the average number of UN civilian police officers deployed in MINUSCA  To estimate U S  civilian personnel costs, we met with State’s Bureau of Budget and Planning to identify the costs of State Foreign Service officers and locally employed staff, based on the number of UN international and national civilian staff deployed to MINUSCA, respectively  We matched the number of State Foreign Service officers for the U S  cost estimate to the number of UN international staff in MINUSCA, with input from State to align the grade levels  The estimated costs for Foreign Service officers include average salaries based on State’s Foreign Service salary tables and State’s allowances specific to CAR, including local cost of living, post hardship differential, and danger pay  We also met with State Bureau of Budget and Planning officials to estimate other costs for Foreign Service officers, which we included in our cost estimate, including post assignment travel, administrative support costs, residential furnishings, and residential guards, among others, but we did not assess the reliability of these additional costs provided by State  In addition, State’s Bureau of Overseas Buildings Operations provided the actual costs of residential leases for Foreign Service officers in CAR in fiscal year 2017, which we used to estimate the cost of housing Foreign Service officers in CAR  We also matched the number of State locally employed staff to the number of UN national staff deployed to MINUSCA and added their average salaries and other costs in CAR based on data provided by State’s Bureau of the Comptroller and Global Financial Services  While MINUSCA’s expenditures also included costs for sending an annual average of up to about 200 UN volunteers to CAR, State officials told us that the United States generally would not send volunteers through its assistance efforts to a high-risk post, such as CAR  Therefore, we did not include any costs related to volunteers in the cost estimate  We also did not include costs related to host-government-provided personnel serving in MINUSCA  In addition, UN expenditures included about $7 million for “quick-impact projects” to support local government infrastructure and civil society initiatives  We did not include comparable costs for quick-impact projects in our U S  cost estimate because we did not have a basis for matching these costs  To identify factors that affect cost differences between MINUSCA and a hypothetical, comparable operation implemented by the United States, we reviewed the U S  cost estimate generated in conjunction with DOD, IDA, and State officials, and identified significant areas of cost for the United States and the assumptions incorporated in the estimate or factors specified by U S  officials that drive those costs  We compared the U S  cost estimate, including these significant areas of cost, to UN costs to identify differences  We interviewed U S  and UN officials regarding U S  and UN standards and policies that explain differences between MINUSCA costs and the estimated costs of a U S  operation  To identify stakeholder views on the relative strengths of UN and U S  peacekeeping operations, we reviewed UN reports on peacekeeping operations and interviewed UN, DOD, and State officials  In addition, we reviewed GAO’s 2006 report comparing the costs as well as the strengths of a UN peacekeeping operation in Haiti with those of a hypothetical U S  operation  We conducted our review from February 2017 through February 2018 in accordance with generally accepted government auditing standards  Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives  We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives  In addition to the individual named above, Drew Lindsey (Assistant Director), Howard Cott, Juan Pablo Avila-Tournut, Debbie Chung, Martin de Alteriis, Neil Doherty, Jennifer Leotta, Caitlin Mitchell, Elizabeth Repko, and Alex Welsh made significant contributions to this report 

ground_truth: To promote international peace and security, the UN had 16 ongoing peacekeeping operations worldwide as of June 30, 2017, with a total budget of almost $8 billion in UN fiscal year 2017 and contributions of over 100,000 military, police, and civilian personnel from more than 120 countries. The United States is the largest financial contributor to UN peacekeeping operations, providing an average of about 28 percent of total funding annually. The Department of State Authorities Act, Fiscal Year 2017, includes a provision for GAO to compare the costs, strengths, and limitations of UN and U.S. peacekeeping operations. This report (1) compares the reported costs of a specific UN operation to the estimated costs of a hypothetical, comparable operation implemented by the United States; (2) identifies factors that affect cost differences; and (3) identifies stakeholder views on the relative strengths of UN and U.S. peacekeeping operations. GAO worked with the UN, DOD, and State to generate a cost estimate of a hypothetical U.S.-led operation in the Central African Republic comparable to MINUSCA. GAO developed this estimate using DOD's cost estimating tool for contingency operations and State data on civilian costs, assuming a U.S. operation using roughly the same levels of military and civilian personnel as MINUSCA. The cost estimate should not be construed as suggesting that the United States would likely implement such an operation in the Central African Republic or that it would implement such an operation in the same way. GAO is making no recommendations. Based on United Nations (UN) and Departments of Defense (DOD) and State (State) data, GAO estimates that it would cost the United States more than twice as much as it would cost the UN to implement a hypothetical operation comparable to the UN Multidimensional Integrated Stabilization Mission in the Central African Republic (MINUSCA). MINUSCA cost the UN approximately $2.4 billion for the first 39 months of the operation. GAO estimates that a hypothetical U.S. peacekeeping operation in the Central African Republic of roughly the same size and duration would cost nearly $5.7 billion—almost eight times more than the $700 million the United States contributed to MINUSCA over the same time period. Various factors affect differences between the actual cost of MINUSCA and the estimated cost of a hypothetical, comparable U.S. operation in the Central African Republic. The United States and the UN would source and transport some supplies and equipment differently, affecting the cost of both operations; for example, the United States would airlift water into the Central African Republic, while the UN does not do so to the same extent. The United States also would incur the cost of civilian police and military reservist salaries, while the UN does not pay any troop or police salaries. Finally, some higher standards for facilities, intelligence, and medical services increase the U.S. cost estimate relative to UN costs for similar operational elements. UN and U.S. peacekeeping operations have various relative strengths, according to U.S. and UN officials. These officials said that, because the UN is a multilateral organization, UN peacekeeping operations have international acceptance and are more likely to be viewed as impartial. Officials also said that the UN enjoys global access to expertise and experience, and can leverage assistance from multilateral donors and development banks. Relative strengths of a U.S. peacekeeping operation would include faster deployment and superior command and control, logistics, intelligence, and counterterrorism capability, according to U.S. and UN officials.