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



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

Report 1: The Navy currently has 51 attack submarines—comprising 33 Los Angeles class, 3 Seawolf class, and 15 Virginia class submarines (see fig  1)  Attack submarines are homeported at bases in the United States: in New London, Connecticut; Pearl Harbor, Hawaii; Norfolk, Virginia; San Diego, California; and Bangor, Washington; 4 are homeported overseas, in the U S  territory of Guam  Submarine Safety Controls and Culture On April 10, 1963, the USS Thresher (SSN 593) sank during deep submergence tests off the coast of New England  One hundred and twelve officers and enlisted sailors and 17 civilians perished in the tragedy  The accident investigation concluded that the Navy did not have adequate procedures in place to prevent and respond to a catastrophic flooding incident  time, and that maintenance delays reduce the amount of time during which ships and submarines are available for training and operations  Submarine fleet and squadron officials emphasized the strict safety culture that permeates the submarine community  This emphasis on meeting safety certification criteria means that the Navy operates a supply-based submarine force that does not compromise on adherence to training and maintenance standards to meet combatant commander demands, according to these officials (see sidebar)  Officials added that the Navy will delay deployment dates if necessary to ensure that these standards are met  As a result, deployed readiness is high and attack submarines are in excellent materiel condition as compared with the rest of the Navy fleet  The loss of the USS Thresher and its crew spurred the Navy to establish stringent safety requirements for submarines to prevent another loss at sea  Following the accident, the Navy established submarine safety certification criteria to provide maximum reasonable assurance that critical systems would protect the crew from flooding and allow the submarine to conduct an emergency surfacing should flooding occur  This program, known as SUBSAFE, is still in use today, to ensure that these critical systems receive a high quality of work and that all work is properly documented  According to the Navy, the SUBSAFE certification status of a submarine is fundamental to its mission capability, as it provides a thorough and systematic approach to quality, and to a culture that permeates the entire submarine community  According to Navy officials, since the SUBSAFE program was established in 1963, no SUBSAFE-certified submarine has ever been lost  The Navy has been unable to begin or complete the vast majority of its attack submarine maintenance periods on time resulting in significant maintenance delays and operating and support cost expenditures  Our analysis of Navy maintenance data shows that between fiscal year 2008 and the end of fiscal year 2018, attack submarines will have incurred 10,363 days of idle time and maintenance delays as a result of delays in getting into and out of the shipyards  Our analysis found that the primary driver affecting attack submarines are delays in completing depot maintenance  For example, of the 10,363 total days of lost time since fiscal year 2008, 8,472 (82 percent) were due to depot maintenance delays  As we previously reported, completing ship and submarine maintenance on time is essential to Navy readiness, as maintenance periods lasting longer than planned could reduce the number of days during which ships and crews are available for training or operations  Attack submarines also face delays in beginning maintenance when the public shipyards have no available capacity, in some cases forcing submarines to idle pierside because they are no longer certified to conduct normal operations  According to Navy officials, the SUBSAFE program—its program to ensure and certify submarine safety—requires submarines to adhere to strict maintenance schedules and pass materiel condition assessments before they are allowed to submerge  Attack submarines that go too long without receiving required maintenance are at risk of having their materiel certification expire  Should this certification expire, these submarines are restricted to sitting idle, pierside, while they wait until a shipyard has the capacity to begin their maintenance period (see fig  2)  We found that since fiscal year 2008, 14 attack submarines have spent a combined 61 months (1,891 days) idling while waiting to enter shipyards for maintenance  Idle time incurred while waiting to begin a maintenance period is often coupled with maintenance delays while at the shipyards, thus compounding total delays  We also found that the Navy incurs significant costs in operating and supporting submarines that are experiencing maintenance delays and idle time  We analyzed the operating and support costs the Navy incurs on average to estimate the costs of crewing, maintaining, and supporting attack submarines that are delayed in getting into and out of the shipyards  Using historical daily cost data the Navy adjusted for inflation, we estimated that since fiscal year 2008 the Navy has spent more than $1 5 billion in fiscal year 2018 constant dollars on attack submarines sitting idle while waiting to enter the shipyards, and on those delayed in completing their maintenance at the shipyards (see table 1)  While the Navy would incur these costs regardless of whether the submarine was delayed, idled, or deployed, our estimate of $1 5 billion represents costs incurred from fiscal year 2008 through fiscal year 2018 for attack submarines without receiving any operational capability in return  While acknowledging the magnitude of these costs, Navy officials stated that there may be some benefits that could be realized from these operating and support costs since crews on idle attack submarines can conduct some limited training  Operating and support costs include payment of crew salaries, purchasing of spare parts, and conducting of maintenance, among other things, but they do not represent the full operational impact incurred by the Navy from the idle time and maintenance delays  For example, attack submarine depot-level maintenance requires the use of a drydock, and officials from the three public shipyards we visited told us that their drydock capacity was limited  A delayed attack submarine maintenance period can restrict the use of a drydock for much longer than originally anticipated, thereby preventing the shipyard from using that drydock to maintain other vessels, including other types of ships, or to conduct necessary repairs on the facilities  The Navy has started to address workforce shortages and facilities needs at the public shipyards  These efforts to address the Navy’s maintenance challenges are important steps, but they will require several years of sustained management attention to reach fruition  As we reported in September 2017, maintenance on ships and submarines may be delayed for numerous reasons, including workforce gaps and inexperience, the poor condition of facilities and equipment, parts shortages, changes in planned maintenance work, and weather  According to Navy officials, all of these issues continue to affect the Navy’s ability to complete attack submarine maintenance on time  According to officials, the Navy has begun to address some of these challenges  For example: The public shipyards have been hiring to address workforce shortages  The number of civilian full-time employees at the shipyards increased from 25,087 in 2007 to 34,160 in 2017, with a goal to reach 36,100 by 2020  Navy officials cautioned that this newly hired workforce is largely inexperienced and will require time to attain full proficiency  The Navy has released a plan to guide public shipyard capital investments  In September 2017 we reported that the Navy projected an inability to support 50 planned submarine maintenance periods over the ensuing 23 years, due to capacity and capability shortfalls at the public shipyards  We recommended that the Navy develop a comprehensive plan for shipyard capital investment  In February 2018 the Navy published its shipyard optimization plan, outlining an estimated $21 billion investment needed to address shipyard facility and equipment needs over 20 years to meet the operational needs of the current Navy fleet, but not the larger fleet size planned for the future  While the public shipyards have operated above capacity for the past several years, attack submarine maintenance delays are getting longer and idle time is increasing  The Navy expects the maintenance backlogs at the public shipyards to continue  We estimate that, as a result of these backlogs, the Navy will incur approximately $266 million in operating and support costs in fiscal year 2018 constant dollars for idle submarines from fiscal year 2018 through fiscal year 2023, as well as additional depot maintenance delays  The Navy may have options to mitigate idle time and maintenance delays  For example, officials at the private shipyards—General Dynamics Electric Boat and Huntington Ingalls Industries-Newport News Shipbuilding—told us that they will have available capacity for repair work for at least the next 5 years  Although the Navy has shifted about 8 million man-hours in attack submarine maintenance to private shipyards over the past 5 years, it has done so sporadically, having decided to do so in some cases only after experiencing lengthy periods of idle time  According to private shipyard officials, the sporadic shifts in workload have resulted in repair workload gaps that have disrupted private shipyard workforce, performance, and capital investment—creating costs that are ultimately borne in part by the Navy  We believe that the Navy has not fully mitigated this challenge because it has not completed a comprehensive business case analysis to inform maintenance workload allocation across public and private shipyards, and to proactively minimize attack submarine idle time and maintenance delays  Such an analysis would help the Navy better assess private shipyard capacity to perform attack submarine maintenance and would help it incorporate a complete accounting of all costs, benefits, and risks, including: the large operating and support costs of having attack submarines sitting idle; the qualitative benefits associated with providing additional availability to the combatant commanders; and the potential for additional work at private shipyards to reduce schedule risk to submarine construction programs by allowing the yards to build and maintain a stable shipyard workforce  The April 2011 DOD Product Support Business Case Analysis Guidebook provides standards for DOD’s process for conducting analyses of costs, benefits, and risks  It states that data sources used to conduct a business case analysis should be comprehensive and should include both quantitative and qualitative values  It notes that benefits, such as the availability of a weapon system, may be qualitative in nature, and that DOD should evaluate all possible support options, to include government- and contractor-provided maintenance  Navy leadership has acknowledged that they need to be more proactive in leveraging private shipyard repair capacity, but officials cautioned that maintenance could cost more at a private shipyard than at a public shipyard  However, without a complete accounting of all costs, benefits, and risks, the Navy will remain unable to determine whether the cost of performing a maintenance period at a private shipyard would outweigh the mission benefits of having reduced idle time, additional operational availability, and the potential for reduced risk to submarine construction programs  The nation’s investment in attack submarines provides the United States an asymmetric advantage to gather intelligence undetected, attack enemy targets, and insert special forces, among other capabilities  However, the Navy’s attack submarine fleet has suffered from persistent and costly maintenance delays  Although the Navy has several activities underway to reduce maintenance delays for the attack submarine fleet, it has not yet taken additional steps to maximize attack submarine readiness that fully address challenges such as the allocation of maintenance periods between public and private shipyards  Without addressing this challenge, the Navy will not achieve the full benefit of the nation’s investment in its attack submarines, and it risks continued expenditure of operating and support funding to crew, maintain, and support attack submarines that provide no operational capability because they are delayed in getting into and out of maintenance  The Secretary of the Navy should ensure that the Chief of Naval Operations conducts a business case analysis to inform maintenance workload allocation across public and private shipyards; this analysis should include an assessment of private shipyard capacity to perform attack submarine maintenance, and should incorporate a complete accounting of both (a) the costs and risks associated with attack submarines sitting idle, and (b) the qualitative benefits associated with having the potential to both mitigate risk in new submarine construction and provide additional availability to the combatant commanders  We provided a draft of the classified version of the report to DOD for review and comment  That draft contained the same recommendation as this unclassified version as well as three additional recommendations DOD deemed sensitive  In written comments provided by DOD (reprinted in appendix II), DOD concurred with our recommendation stating that it has taken the first steps to take a more holistic view of submarine maintenance requirements and impacts across both the public and private shipyards  The Navy also provided technical comments, which we incorporated as appropriate  We are sending copies of this report to congressional committees; the Secretary of Defense; the Secretary of the Navy, and other interested parties  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) 512-3489 or pendletonj@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 IV  To assess the extent to which the Navy has experienced maintenance delays in its attack submarine fleet, we analyzed attack submarine maintenance delay and idle time data from Naval Sea Systems Command, and we reviewed prior GAO work on shipyard maintenance delays  The Navy determines depot maintenance delays by counting each day in which a submarine maintenance period extends beyond the planned completion date  Two Navy offices within Naval Sea Systems Command—that is, the Logistics, Maintenance, and Industrial Operations office and Program Executive Office Submarines—track days incurred from depot-level maintenance delays and idle time  To determine the total number of days of maintenance delays for each fiscal year within our scope, we subtracted the planned completion date from the actual completion date to produce the number of days of maintenance delays for each maintenance period for each submarine  We added together the days of maintenance delays across all attack submarines for each fiscal year, and then added the fiscal year totals to produce the overall total  Although the data included some maintenance periods that began before fiscal year 2008, we counted days of maintenance delays only from periods that were incurred in fiscal years 2008 through 2018  We also tracked the total number of days that the Navy completed maintenance periods ahead of schedule—that is, 153—but we noted these separately instead of subtracting them from the total number of days of maintenance delays  To estimate costs associated with these delays, we analyzed annual data from fiscal years 2011 through 2017 (the most current data available at the time of our review) from the Navy’s Visibility and Management of Operating and Support Costs system  We also reviewed prior work on determining the operating and support costs of Navy ships  The Navy calculates total operating and support expenditures for each attack submarine on an annual basis, as well as the yearly average expenditure for each attack submarine class, including Los Angeles class, Seawolf class, and Virginia class blocks one and two  For each class, we converted the Navy’s annual class averages into daily average costs by adding the annual class averages together for each year that data were available, fiscal years 2011 through 2017, then dividing that number by the total number of days  We then multiplied the daily class average by the total number of days of maintenance delays and idle time incurred by submarines within that class, according to our calculations outlined above, between fiscal year 2008 and fiscal year 2018, and we added these totals together to produce the total estimated operating and support cost for days of maintenance delays and idle time incurred during this period  The data did not include annual class average costs for fiscal years 2008, 2009, 2010, or 2018  However, the annual class averages for fiscal years 2011 through 2017 did not show significant variation, so we applied these averages to 2008, 2009, 2010, and 2018  To assess the extent to which the Navy has addressed any challenges and developed mitigation plans for any maintenance delays, we reviewed the Navy’s plans to address attack submarine maintenance delays and interviewed Navy headquarters, fleet, and squadron officials, attack submarine crews, and public and private shipyard officials to understand any plans to address attack submarine maintenance delays and idle time  We analyzed data on factors contributing to attack submarine maintenance delays, such as cannibalization rates  We visited three of the four public shipyards, including Pearl Harbor Naval Shipyard and Intermediate Maintenance Facility, Portsmouth Naval Shipyard, and Norfolk Naval Shipyard, to observe operations, training, and the condition of the facilities and equipment, and to interview officials about challenges affecting operational efficiency and performance  We also met with Navy maintainers at Naval Station Norfolk and Naval Submarine Base New London, and with the crew of the submarine tenders USS Frank Cable (AS-40) and USS Emory S  Land (AS-39) in Guam  We toured the two private shipyards that conduct attack submarine repair work—General Dynamics Electric Boat and Huntington Ingalls Industries-Newport News Shipbuilding—and interviewed executives at both locations  We also toured attack submarines and met with crew leadership, selected according to which submarines and crews were available for tours at each of the sites we visited  We visited the USS Boise (SSN 764) at Naval Station Norfolk and four attack submarines in depot-level maintenance: the USS Albany (SSN 753), the USS Jefferson City (SSN 759), the USS New Mexico (SSN 779), and the USS Springfield (SSN 761)  We met with the crews of two attack submarines assigned to the operating forces at the time of our visit, the USS Missouri (SSN 780) and the USS North Dakota (SSN 784)  We evaluated the Navy’s plans to address any challenges against criteria in federal standards for internal control, which state that agencies should evaluate performance in achieving key objectives and addressing risks; the Department of Defense’s business case analysis guidebook, which provides standards for the process used to conduct analyses of costs, benefits, and risks; the Project Management Book of Knowledge, which provides best practices for project management; and the Secretary of the Navy’s December 2017 Strategic Readiness Review, which calls for the early identification of systemic risks before problems occur  To assess the reliability of the data sources for conducting analyses to address all of the objectives in this report, we reviewed systems documentation and interviewed officials to understand system operating procedures, organizational roles and responsibilities, and error-checking mechanisms  We selected the time frames for each of the data series above after assessing their availability and reliability, to maximize the amount of data available for us to make meaningful comparisons  We assessed the reliability of each of the data sources  The Navy provided information based on our questions regarding data reliability, including information on an overview of the data, data-collection processes and procedures, data quality controls, and overall perceptions of data quality  The Navy provided documentation of how the systems are structured and what written procedures are in place to help ensure that the appropriate information is collected and properly categorized  Additionally, we interviewed Navy officials to obtain further clarification on data reliability, discuss how the data were collected and reported, and explain how we planned to use the data  We also conducted our own error checks to look for inaccurate or questionable data, and we discussed with officials any data irregularities we found  We conducted these assessments on the following data for attack submarines: Navy deployed and surge-ready submarines from fiscal years 2011 through 2018; maintenance timeliness from fiscal years 2000 through 2018; idle time from fiscal years 2008 through 2018; operating and support costs from fiscal years 2011 through 2017; and cannibalization rates from 2012 through 2017  Some of these data were used in prior reports, and their reliability had previously been assessed  After further assessing any data that we had not recently used, we determined that they were sufficiently reliable for the purposes of summarizing attack submarine readiness trends and related information  We interviewed officials, and where appropriate obtained documentation, at the following locations: Office of the Chief of Naval Operations Undersea Warfare Division (N97) Warfare Integration Division (N83) U S  Fleet Forces Command Commander, Submarine Force, U S  Atlantic Fleet Commander, Submarine Squadron 4 Commander, Regional Support Group Groton Commander, Submarine Force, U S  Pacific Fleet Commander, Submarine Squadron 1 Commander, Submarine Squadron 7 Commander, Submarine Squadron 15 Naval Sea Systems Command (NAVSEA) Logistics, Maintenance, and Industrial Operations (NAVSEA 04) Program Executive Office, Submarines Attack Submarine Program Office (PMS 392) Submarine Maintenance Engineering, Planning, and Procurement (SUBMEPP) Supervisor of Shipbuilding, Conversion, and Repair (SUPSHIP) Newport News, Virginia Navy Education and Training Command Submarine Learning Facility Norfolk Navy Board of Inspection and Survey Norfolk Naval Shipyard, Norfolk, Virginia Pearl Harbor Naval Shipyard and Intermediate Maintenance Facility, Pearl Harbor, Hawaii Portsmouth Naval Shipyard, Kittery, Maine Newport News Shipbuilding, Virginia, operated by Huntington Ingalls Industries Electric Boat, Groton, Connecticut, operated by General Dynamics The performance audit upon which this report is based was conducted from August 2017 to October 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  We worked with DOD to prepare this unclassified version of the report for public release  This public version was also prepared in accordance with these standards  Report numbers with a C or RC suffix are Classified  Classified reports are available to personnel with the proper clearances and need to know, upon request  Columbia Class Submarine: Immature Technologies Present Risks to Achieving Cost Schedule and Performance Goals  GAO-18-158  Washington, D C : Dec  21, 2017  Navy Readiness: Actions Needed to Address Persistent Maintenance, Training, and Other Challenges Affecting the Fleet  GAO-17-809T  Washington, D C : Sept  19, 2017  Naval Shipyards: Actions Needed to Improve Poor Conditions that Affect Operations  GAO-17-548  Washington, D C : Sept  12, 2017  Navy Readiness: Actions Needed to Address Persistent Maintenance, Training, and Other Challenges Facing the Fleet  GAO-17-798T  Washington, D C : Sept  7, 2017  Military Readiness: DOD’s Readiness Rebuilding Efforts May Be at Risk without a Comprehensive Plan  GAO-16-841  Washington, D C : Sept  7, 2016  Navy and Marine Corps: Services Face Challenges to Rebuilding Readiness  GAO-16-481RC  Washington, D C : May 25, 2016  (SECRET//NOFORN) Military Readiness: Progress and Challenges in Implementing the Navy’s Optimized Fleet Response Plan  GAO-16-466R  Washington, D C : May 2, 2016  Navy Force Structure: Sustainable Plan and Comprehensive Assessment Needed to Mitigate Long-Term Risks to Ships Assigned to Overseas Homeports  GAO-15-329  Washington, D C : May 29, 2015  In addition to the contact named above, Suzanne Wren, Assistant Director; Chris Watson, Analyst in Charge; Herb Bowsher; Chris Cronin; Ally Gonzalez; Cynthia Grant; Carol Petersen; Amber Sinclair; and Cheryl Weissman made key contributions to this report 


Report 2: Spinal cord injuries are complex, lifelong injuries that typically result from acute traumatic damage to the spinal cord or nerves within the spinal column  In spinal cord injury patients, certain nervous system functions may be impaired temporarily or permanently lost, depending on the level and severity of the patient’s injury  In addition to lower level nervous system functioning, spinal cord injury patients may develop secondary medical complications that can further decrease functional independence and quality of life, including, but not limited to: Autonomic dysreflexia: a condition that may result in life threatening hypertension—high blood pressure—due to impaired nervous system response, below the level of spinal cord injury  Depression: a medical mood disorder—commonly affecting about one in five spinal cord injury patients—that can cause physical and psychological symptoms (including changes in sleep and appetite, and thoughts of death or suicide)  Impaired bowel and bladder functioning: potential inability to move waste through the colon and control, stop or release, urine—which can lead to other life-threatening illnesses (such as autonomic dysreflexia) and/or infections  Pressure ulcers: a common complication affecting up to 80 percent of spinal cord injury patients that results from an area of the skin or underlying tissue that is damaged due to decreased blood flow, which can occur after extended periods of inactive sitting or lying, among other ways  Pressure ulcers—also known as pressure sores or wounds—can occur years after initial injury and may also result in life- threatening infections or amputation  Spasticity: a common condition that affects 65 to 78 percent of spinal cord injury patients and can result in symptoms ranging from mild muscle stiffness to severe, uncontrollable leg movements  Syringomyelia: a rare disorder that occurs when cerebrospinal fluid— normally found outside of the spinal cord and brain—enters the interior of the spinal cord to form a cyst known as a syrinx  This cyst expands and elongates over time, destroying the center of the spinal cord  Symptoms can develop slowly and can include numbness, pain, effects on bowel and bladder function, or paralysis  While this condition can occur as a result of a trauma, such as a spinal cord injury, the majority of cases are associated with a complex brain abnormality  Acquired brain injuries occur after birth and are not hereditary, congenital, degenerative, or a result of birth trauma  Acquired brain injuries result in changes to the brain’s neuronal activity, which can affect the physical integrity, metabolic activity, or functional ability of nerve cells in the brain  Acquired brain injuries can be either non-traumatic or traumatic in nature: non-traumatic brain injuries are caused by an internal force—such as in the case of stroke, tumors, or drowning—and traumatic brain injuries are caused by an external force—such as in the case of car accidents, gunshot wounds, or falls  The severity of brain injury can often result in changes to physical, behavioral, and/or cognitive functioning  For example, according to one source, nearly 50 percent of all people with a traumatic brain injury experience depression within the first year after injury, and nearly two-thirds experience depression within 7 years post- injury  Depression can develop as a result of physical changes in the brain, emotional response to the injury, and other unrelated factors—such as family history  Due to impaired cognitive functioning, traumatic brain injury patients may also experience difficulty communicating, concentrating, and processing and understanding information  Acute care hospitals and LTCHs are paid under different Medicare payment systems by law  Acute care hospitals are paid under the inpatient prospective payment system (IPPS)  LTCHs are paid under the LTCH PPS  Under both systems, Medicare classifies patients based on Medicare diagnosis groups, which organize patients based on their conditions and the care they receive  Medicare payments for LTCHs are typically higher than payments for acute care hospitals, to reflect the average resources required to treat Medicare beneficiaries who need long-term care  Traditionally, all LTCH discharges were paid at the LTCH PPS standard federal payment rate  The Pathway for SGR Reform Act of 2013 modified the LTCH PPS by establishing a two-tiered payment system— such that certain LTCH discharges continue to be paid at the standard rate and others are paid at a generally lower, site-neutral rate  In its March 2013 report, MedPAC described concerns regarding growth in the number of LTCHs and the extent to which some of their patients may otherwise be treated appropriately in less costly settings  To continue to be eligible for the standard rate, the discharge must generally have a preceding acute care hospital stay with either an intensive care unit stay of at least 3 days or an assigned diagnosis group based on the receipt of at least 96 hours of mechanical ventilation services in the LTCH, unless an exception applies  Discharges that do not qualify for the standard rate are to receive a blended site-neutral rate—equal to 50 percent of the site-neutral rate and 50 percent of the standard rate—for discharges in cost reporting periods beginning in fiscal years 2016 through 2019, and the full site-neutral rate for discharges in cost reporting periods beginning in fiscal year 2020  Beginning with cost reporting periods in fiscal year 2020, if fewer than half of an LTCH’s discharges meet the statutory requirements to be paid at the standard rate, the LTCH will no longer receive any payments at that rate for discharges in future cost reporting periods until eligibility for receiving payments under that rate is reinstated  Under this scenario, all discharges in succeeding cost reporting periods would be paid at the generally lower rate that an acute care hospital would receive for providing comparable care until eligibility for receiving payments at the standard rate is reinstated  According to officials from HHS, the department intends to establish a process for how hospitals would have their eligibility for receiving payments at the standard rate reinstated as part of the fiscal year 2020 rule-making cycle  Since the two qualifying hospitals are currently only excepted from the statutory two-tiered payment structure for cost reporting periods beginning during fiscal years 2018 and 2019, these two hospitals must also meet the statutory 50 percent threshold in fiscal year 2020 and beyond in order to receive the standard rate for any future discharges until reinstated  See table 1 for more information on Medicare’s LTCH PPS payment policies  Two LTCHs have qualified for the temporary exception to site-neutral payments, according to CMS officials  Craig Hospital is a private, not-for- profit facility that has specialized in medical treatment, research, and rehabilitation for patients with spinal cord and brain injury since 1956  Craig Hospital is classified as an LTCH for the purposes of Medicare payment, and is licensed as a general hospital by the state of Colorado— which does not have separate designations for LTCHs  Craig Hospital has been selected as one of 14 NIDILRR Spinal Cord Injury Model Systems and one of 16 Traumatic Brain Injury Model Systems and is accredited by the Joint Commission  Shepherd Center is a private, not-for-profit facility that specializes in medical treatment, research, and rehabilitation for people with traumatic spinal cord injury and brain injury—as well as neuromuscular disorders, including multiple sclerosis  Shepherd Center is classified as an LTCH for the purposes of Medicare payment, and as a specialty hospital—which includes LTCHs—by the state of Georgia  Shepherd Center is also currently designated as a NIDILRR Spinal Cord Injury Model System and is accredited by the Joint Commission  Shepherd Center also has several CARF International accredited specialty programs  Specifically, it has CARF-accredited inpatient rehabilitation specialty programs in spinal cord injury and brain injury—for adults, children, and adolescents; and interdisciplinary outpatient medical rehabilitation specialty programs in spinal cord injury and brain injury—for adults, children, and adolescents, among others  More than half of the Medicare discharges in fiscal year 2013 at the two qualifying hospitals—43 of 75 at Craig Hospital and 47 of 88 at Shepherd Center—were within the diagnosis groups designated in section 15009(a) of the 21st Century Cures Act  (See table 2 below for more information ) Patients treated for these diagnosis groups may receive treatment for spinal disorders and injuries; medical back problems; degenerative nervous system disorders; skin grafts for skin ulcers; acquired brain injuries, such as traumatic brain injuries; or other significant traumas with major complicating and comorbid (simultaneous) conditions  Both qualifying hospitals have a variety of specialized inpatient and outpatient programs to help treat the complex health care needs of their patients, including those covered by Medicare  For example, both hospitals have wheelchair positioning clinics that can help prevent skin complications, such as pressure ulcers, that can occur in spinal cord patients  Both hospitals also have programs for those patients who need ventilator support such as diaphragmatic pacing—support for patients with respiratory problems whose diaphragm, lungs, and nerves have limited function—and ventilator weaning programs  In addition to clinical programs, both qualifying hospitals also provide transitional support, such as providing counseling and education to families of patients with these injuries  We found that most Medicare beneficiaries at the two qualifying hospitals need specialized services to manage the chronic, long-term effects of a catastrophic spinal cord or brain injury  Most of these patients are younger than 65 and ineligible for Medicare at the time of their initial injury, according to officials from the qualifying hospitals  Instead, according to officials, these patients typically become eligible for Medicare 2 years or more after their initial injury due to disability  Medicare beneficiaries at the two qualifying hospitals typically need care to manage comorbidities or the associated long-term complications of their injury  Officials from Craig Hospital said a significant number of their Medicare beneficiaries have comorbid conditions—such as diabetes or cardiac problems—upon admission, that can be further complicated by their injury  The officials said managing these comorbidities is as much of a medical challenge as managing the spinal or brain injury  Officials from both qualifying hospitals noted their Medicare beneficiaries who have a spinal cord or brain injury also frequently seek care after initial injury to address secondary complications resulting from their injury, including urinary tract infections; respiratory problems; and pressure ulcers  While the qualifying hospitals primarily treated traumatic spinal cord or brain injuries, we found that their Medicare populations differed from each other during the period from fiscal year 2013 to 2016  Specifically, Craig Hospital  Our review of Medicare claims data indicates more than 50 percent of the 246 Medicare discharges during this time were associated with Medicare diagnosis groups for spinal cord conditions  Specifically, during this time, Craig Hospital’s Medicare discharges were commonly assigned to three diagnosis groups covering spinal procedures and spinal disorders and injuries  For example, officials from Craig Hospital told us that about 60 percent of Medicare beneficiaries in fiscal year 2016 required surgical care for a spinal cord injury  According to officials, most of these patients received surgery for syringomyelia—a complication in spinal cord patients that generally develops years after their initial injury  These officials told us that Craig Hospital provided the pre- and post-operative care for those patients in fiscal year 2016; however, currently, Craig Hospital is only responsible for pre-operative assessments  The remaining 40 percent of their Medicare beneficiaries in fiscal year 2016 received care for new spinal cord injuries  Shepherd Center  Our review of Medicare claims data indicates the most common diagnosis group of the 365 Medicare discharges during this time—fiscal year 2013 to fiscal year 2016—related to treatment for skin grafts that can be associated with pressure ulcers, among other things  Shepherd Center officials confirmed that most of their Medicare beneficiaries received treatment for a pressure ulcer that occurred after initial injury which, as previously noted, can be so severe as to result in life-threatening infections  According to officials, most of their post-injury Medicare beneficiaries receive post-operative care and other wound management services following surgery to treat pressure ulcers, to ensure that the site will not tear again and to avoid reoccurrence  Other diagnosis groups for Medicare patients at Shepherd Center included those for spinal disorders and injuries and extensive operating room procedures unrelated to principal diagnosis  According to officials, beneficiaries in these diagnosis groups received treatment for a range of conditions, including traumatic injuries, urinary tract infections, neurogenic bladder and bowel or respiratory complications  Officials told us the hospital also served Medicare beneficiaries recovering from other acquired brain injuries, such as stroke, and paralyzing neuromuscular conditions, such as multiple sclerosis  Stakeholders we interviewed—including providers at other facilities— noted that traumatic spinal cord and brain injury patients—including those covered by Medicare—require significant levels of care due to the complexity of their injuries as well as the immediate and long-term complications that can occur from the injuries  For example, most stakeholders told us these patients often require lifelong care due to the complexity and reoccurrence of comorbidities or secondary complications  Some of these stakeholders noted, for example, spinal cord and brain injury patients often face mental health or psychosocial conditions, such as depression or anxiety  Some stakeholders also emphasized that many spinal cord injury patients risk secondary complications that may not occur until years after injury, such as pneumonia, pressure ulcers, and other infections  A few stakeholders told us spinal cord and brain injury patients are often among the most complex patients they treat  As such, patients with spinal cord or brain injuries often require interdisciplinary care that covers a wide range of specialties—including physiatry (rehabilitation medicine), neurology, cardiology, and pulmonology—as well as specialized equipment or technology, such as eye glance tools to control call systems or the television  Simulations of Medicare payments illustrate the potential effects of Medicare’s site-neutral payment policies, which were required by law, on the qualifying hospitals  Specifically, our simulations calculated what the qualifying hospitals would have been paid for Medicare patient discharges that occurred in two baseline years—fiscal year 2013 (baseline year 1) and fiscal year 2016 (baseline year 2)—if applicable payment policies from future years (2017 through 2021) were applied to those discharges  We selected two baseline years to account for differences in data, such as the number of discharges, between fiscal year 2016—the most recent year of complete data available at the time we began our analysis—and fiscal year 2013  Table 3 below provides a summary of Medicare discharges and payments to the qualifying hospitals during these two baseline years  Variation in utilization and patient mix across the baseline years allows the simulations to cover a range of possible changes in payments for the two hospitals  Our simulations indicated how Medicare’s payment policies could have affected these baseline payments to each qualifying hospital: Fiscal Year 2017 Blended Site-Neutral Rate Policy: Discharges that do not meet criteria to receive the standard rate are to receive a blended site-neutral rate—equal to 50 percent of the site-neutral rate and 50 percent of the standard rate  We found that while some of the baseline discharges would qualify for the standard rate, most discharges would have been paid at the blended site-neutral rate  Specifically, 8 to 20 percent of Craig Hospital’s baseline Medicare discharges would have qualified for the standard rate, resulting in simulated payments of about $3 86 million (baseline year 1) and $3 22 million (baseline year 2) under blended site-neutral rate policy  For Shepherd Center, between 23 percent and 40 percent of baseline Medicare discharges would have qualified for the standard rate, resulting in simulated payments of about $5 16 million (baseline year 1) and $5 31 million (baseline year 2)  Each of these simulated payments is an increase compared to actual payments made in the baseline years  Fiscal Years 2018 and 2019 Temporary Exception: The qualifying hospitals are receiving the standard rate for all discharges, due to the temporary exception  As a result, simulated payments under the temporary exception are about $3 74 million (baseline year 1) and $3 18 million (baseline year 2) for Craig Hospital and about $5 64 million (baseline year 1) and $5 75 million (baseline year 2) for Shepherd Center, which is an increase compared to actual payments made in the baseline years  Fiscal Year 2020 Two-Tiered Payment Rate: The temporary exception for the qualifying hospitals no longer applies; therefore, the site- neutral rate will apply to discharges not qualifying for the standard rate  We found that both qualifying hospitals would receive some payments at the standard rate, but that most of their discharges would be paid at the lower, site-neutral rate—assuming similar caseloads (e g , patient mix)  As a result, simulated baseline year payments at Craig Hospital are about $3 47 million (baseline year 1) and $3 03 million (baseline year 2), and simulated baseline payments to Shepherd are about $4 42 million (baseline year 1) and $4 55 million (baseline year 2)  The simulated payments therefore decrease compared to those in fiscal year 2019, and also generally decrease compared to actual payments made in the baseline years  Future Years Under 50 Percent Threshold: Under statute, unless 50 percent or more of the hospital’s discharges in cost reporting periods beginning during or after fiscal year 2020 qualify for the standard rate, no subsequent payments will be made to a hospital at that rate in each succeeding cost reporting period  Most of the baseline year discharges did not qualify for the standard rate, and therefore simulated payments are based on the generally lower comparable acute care rate  However, simulated payments stayed about the same between fiscal year 2020 and 2021, in part due to differences in calculations for high-cost outlier payments  A high-cost outlier payment is made to hospitals for those cases that are extraordinarily costly, which can occur because of the severity of the case and/or a particularly long length of stay  Specifically, simulated payments were about $3 49 million (baseline year 1) and $3 02 million (baseline year 2) for Craig Hospital and about $4 24 million (baseline year 1) and $4 16 million (baseline year 2) for Shepherd Center  Without the high-cost outlier payments, the simulated payments would have decreased by at least $2 million  If the mix of patients at Craig Hospital and Shepherd Center changes so that they meet the 50 percent threshold in fiscal year 2020, then simulated payments for fiscal year 2021 could be higher  As of September 2018, Craig Hospital officials told us that they expect to meet the 50 percent threshold with their current patient mix  Shepherd Center officials told us they do not expect to meet the 50 percent threshold  See figures 1 and 2 below for the results of our simulations  Our simulations of payments assume the number and type of Medicare discharges at the two qualifying hospitals remain the same as those in fiscal years 2013 and 2016  However, the full effect of payment policy on future Medicare payments to the qualifying hospitals will depend on three key factors that are subject to change: 1  Severity of patient conditions: Medicare payment is typically higher for more severe injuries, such as a traumatic injury with major comorbidities or complications, relative to less severe injuries  In the two baseline years we used for our simulations—fiscal year 2013 and fiscal year 2016—more than half of the Medicare discharges at the qualifying hospitals were associated with conditions with multiple comorbidities and complications, as indicated by the diagnosis groups, and this level of severity is reflected in the simulation results  Future payments to qualifying hospitals will depend on the extent to which the severity of patient conditions changes over time  2  Volume of discharges meeting criteria for the standard rate: As previously noted, for a hospital to receive the standard rate for a discharge, the discharge must meet certain criteria, such as having a preceding acute care hospital stay with either an intensive care unit stay of at least 3 days or an assigned diagnosis group based on the receipt of at least 96 hours of mechanical ventilation services in the LTCH  Our simulations reflect that in the two baseline years, about 23 percent of the fiscal year 2013 discharges and about 40 percent of the fiscal year 2016 discharges met the criteria to receive the standard rate for Shepherd Center; and about 8 percent of the fiscal year 2013 discharges and about 20 percent of the fiscal year 2016 discharges met the criteria for Craig Hospital  Changes to these amounts could affect future payments to the qualifying hospitals  In particular, if 50 percent or more of either hospital’s discharges beginning in fiscal year 2020 meet the standard rate criteria, then the hospitals would be eligible for payments at the standard rate in fiscal year 2021, which may result in higher payments compared to our simulations  3  Payment adjustments: LTCHs may receive a payment adjustment for certain types of discharges, such as short-stay outliers, interrupted stays, or high-cost outliers  In particular, most discharges at Craig Hospital received high-cost outlier payments (additional payments for extraordinarily costly cases) during the two baseline years—76 percent in fiscal year 2013 and 85 percent in fiscal year 2016  At Shepherd Center, at least 40 percent of discharges during the two baseline years received high-cost outlier payments—about 42 percent in fiscal year 2013 and about 58 percent in fiscal year 2016  The amount of future payments to qualifying hospitals will depend on the extent to which they continue to have a high proportion of discharges with high-cost outlier payments  In addition to the effect on payments, officials from both qualifying hospitals and some stakeholders we interviewed noted that the LTCH site-neutral payment policies may result in fewer services provided and fewer patients served by the qualifying hospitals and other LTCHs  For example, officials from Craig Hospital told us they stopped providing post- operative care to patients requiring spinal surgery, such as patients with syringomyelia, in 2016—instead referring them to other facilities—in part because these discharges do not meet the criteria for the standard rate  As of September 2018, they told us they do not plan to provide this care in the future unless the temporary exception is extended  Officials from Shepherd Center told us while they have not yet made changes to services they offer to Medicare patients, they may limit which Medicare beneficiaries they serve in the future  For example, they told us that most of their Medicare beneficiaries were admitted from home or sought care in their outpatient clinic  When the temporary exception expires after fiscal year 2019, hospital officials expected that these patients will not qualify for the standard rate  Shepherd Center officials said they may not be able to serve similar patients in future years  MedPAC officials and some stakeholders—a specialty association and health care providers with experience treating patients with similar conditions at other LTCHs—told us that some LTCHs have changed the services they offer and the patients they treat to increase the proportion of discharges that qualify for the standard rate  For example, MedPAC officials cited reports that indicate how some LTCHs have adjusted to the site-neutral policies  For example, a 2018 MedPAC report indicated that LTCHs in one large for-profit chain were able to make adjustments so that, as of September 30, 2016, close to 100 percent of their Medicare discharges met the criteria to receive the standard rate  A representative from an LTCH association told us that many LTCHs have adjusted their patient mix by increasing the number of discharges that meet criteria for the standard rate and turning away some Medicare beneficiaries to reduce the number of discharges subject to the site-neutral rate  The representative noted that certain LTCHs have already been able to adjust their patient mix because they have existing programs in place that focus on chronic, critically ill patients who would have a preceding acute care hospital stay  The representative told us that some LTCHs specialize in care for patients who do not meet the criteria to receive the standard rate and would generally be paid at the site-neutral rate; therefore, changing their patient mix is not a viable strategy for these LTCHs  According to the stakeholder, as of February 2018, about two-thirds of all LTCHs are above the 50 percent threshold  Providers from another LTCH told us that before the site-neutral payment policy went into effect, only about 40 to 45 percent of its discharges met criteria for the standard rate  However, they worked to ensure most patients referred to the LTCH would qualify for the standard rate  Officials told us patients who do not meet the criteria for that rate typically either stay longer in the acute care hospital or are transferred to a different post-acute care setting, such as a skilled nursing facility  Officials noted that, in both cases, the patient may not receive the specialized services often required for their injuries, including those patients with spinal cord or brain injuries  A provider we interviewed from another LTCH said that, historically, the LTCH has accepted patients who acquire pressure ulcers at home following discharge, but they may choose not to continue this practice because the patients’ discharges would not meet the criteria to receive the standard rate  A few of these stakeholders told us some LTCHs are in markets that do not have alternative providers of care, such as skilled nursing facilities, for patients who do not meet the criteria  These LTCHs may have difficulty adjusting their patient mix to avoid site-neutral payments  For example, a provider from one LTCH said his facility continues to take “site-neutral patients” because those patients often do not have another option to receive the specialized services they need

ground_truth: According to the Navy, its 51 attack submarines provide the United States an asymmetric advantage to gather intelligence undetected, attack enemy targets, and insert special forces, among others. These capabilities make attack submarines some of the most–requested assets by the global combatant commanders. GAO was asked to review the readiness of the Navy's attack submarine force. This report discusses the extent to which the Navy (1) has experienced maintenance delays in its attack submarine fleet and costs associated with any delays; and (2) has addressed any challenges and developed mitigation plans for any maintenance delays. GAO analyzed readiness information from fiscal years 2008-2018, operating and support costs, maintenance performance, and other data; visited attack submarines and squadrons; and interviewed public and private shipyard and fleet officials. This is a public version of a classified report issued in October 2018. Information the Department of Defense deemed classified or sensitive, such as attack submarine force structure requirements and detailed data on attack submarine maintenance delays, has been omitted. The Navy has been unable to begin or complete the vast majority of its attack submarine maintenance periods on time resulting in significant maintenance delays and operating and support cost expenditures. GAO's analysis of Navy maintenance data shows that between fiscal year 2008 and 2018, attack submarines have incurred 10,363 days of idle time and maintenance delays as a result of delays in getting into and out of the shipyards. For example, the Navy originally scheduled the USS Boise to enter a shipyard for an extended maintenance period in 2013 but, due to heavy shipyard workload, the Navy delayed the start of the maintenance period. In June 2016, the USS Boise could no longer conduct normal operations and the boat has remained idle, pierside for over two years since then waiting to enter a shipyard (see figure). GAO estimated that since fiscal year 2008 the Navy has spent more than $1.5 billion in fiscal year 2018 constant dollars to support attack submarines that provide no operational capability—those sitting idle while waiting to enter the shipyards, and those delayed in completing their maintenance at the shipyards. The Navy has started to address challenges related to workforce shortages and facilities needs at the public shipyards. However, it has not effectively allocated maintenance periods among public shipyards and private shipyards that may also be available to help minimize attack submarine idle time. GAO's analysis found that while the public shipyards have operated above capacity for the past several years, attack submarine maintenance delays are getting longer and idle time is increasing. The Navy may have options to mitigate this idle time and maintenance delays by leveraging private shipyard capacity for repair work. But the Navy has not completed a comprehensive business case analysis as recommended by Department of Defense guidelines to inform maintenance workload allocation across public and private shipyards. Navy leadership has acknowledged that they need to be more proactive in leveraging potential private shipyard repair capacity. Without addressing this challenge, the Navy risks continued expenditure of operating and support funding to crew, maintain, and support attack submarines that provide no operational capability because they are delayed in getting into and out of maintenance. GAO recommends that the Navy conduct a business case analysis to inform maintenance workload allocation across public and private shipyards. The Department of Defense concurred with GAO's recommendation.

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



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



Report 2:  The provider emphasized concerns about the long-term viability of caring for those patients at the facility, because their care is paid at lower rates  Our review of Medicare claims data, other information, and interviews with stakeholders indicated the two qualifying hospitals treated Medicare beneficiaries with different conditions than most of those treated at other LTCHs  Our analysis of Medicare claims data indicates Craig Hospital and Shepherd Center treat very few patients in the Medicare diagnosis groups that are most common to other LTCHs  Specifically, for several years, MedPAC has reported that LTCH patient discharges are concentrated in a relatively small number of diagnosis groups  For example, in March 2018, MedPAC reported that 20 diagnosis groups accounted for over 61 percent of LTCH discharges at both for-profit and not-for-profit facilities, in fiscal year 2016  However, in fiscal year 2016, these diagnosis groups accounted for approximately 30 percent of Medicare discharges—26 out of 88—at Shepherd Center, and most of these discharges fell within a single diagnosis group which covers a range of conditions  Craig Hospital did not discharge any Medicare beneficiaries assigned to these 20 diagnosis groups, in fiscal year 2016  The seven diagnosis groups that were used in the statutory criteria to except Craig Hospital and Shepherd Center from site-neutral payments were also not among these 20 diagnosis groups  For more information on the 20 diagnosis groups common to LTCHs in fiscal year 2016, see Appendix III, table 5  Our review of Medicare claims data and other information indicates the two qualifying hospitals also treat a relatively small number of Medicare beneficiaries, a key distinguishing factor from most other LTCHs  In March 2018, MedPAC reported that, on average, Medicare beneficiaries account for about two-thirds of LTCH discharges  However, Medicare claims data and other information provided by the two qualifying hospitals indicate Medicare beneficiaries account for a significantly smaller proportion (about 8 percent) of patients discharged from Craig Hospital and Shepherd Center in 2016  Specifically, 40 of the 486 patients discharged from Craig Hospital in fiscal year 2016 and 75 of the 912 patients discharged from Shepherd Center in calendar year 2016, were Medicare beneficiaries  Officials from the qualifying hospitals told us they treat few Medicare patients primarily because of the younger average age of persons with spinal cord injuries and acquired brain injuries  While patients with spinal cord and brain injuries may receive care in other LTCHs, most stakeholders we interviewed also suggested the two qualifying hospitals treat patients that are different from those treated at most other LTCHs, and can offer specialized care  Officials from the two qualifying hospitals told us that, relative to most other facilities—including most traditional LTCHs—they offer a more complete continuum of care to meet the needs of patients at different stages of spinal cord and brain injury treatment, without the need to transfer to different facilities  Officials also stated that, unlike most traditional LTCHs, they are able to offer more specialized care for patients with spinal cord and brain injuries, including more comprehensive rehabilitation services  Stakeholders we interviewed generally agreed that the two qualifying hospitals have developed expertise in treating spinal cord and brain injury patients and offer intensive rehabilitation services that are not provided in most other LTCHs  In addition, officials from the Colorado Department of Health Care Policy & Financing noted that Craig Hospital treats a patient population that is different from most other LTCHs in the state of Colorado  Specifically, according to officials, in comparison to other LTCHs in the state, Craig Hospital treats: (1) a higher percentage of patients with more severe conditions, (2) more patients from outside the state of Colorado, (3) fewer patients requiring ventilator weaning or requiring wound care— conditions typically characteristic of LTCH patients—and (4) patients that are, on average, younger than most other LTCHs in the state of Colorado  In addition, a 2014 study of LTCHs conducted for the Georgia Department of Community Health found Shepherd Center was “distinctly different” from other LTCHs in the state of Georgia, and most LTCHs nationwide  Most stakeholders we interviewed suggested some IRFs provide specialty care to patients with catastrophic spinal cord, acquired brain injuries, or other paralyzing neuromuscular conditions  Most of the stakeholders we interviewed noted that—like the two qualifying hospitals—some IRFs have the expertise to treat patients with catastrophic spinal cord, acquired brain injuries, or other paralyzing neuromuscular conditions patients and thus, may also treat patients with similar conditions  According to CMS officials, IRFs are specifically designed to provide post-acute rehabilitation services to patients with spinal cord injuries, brain injuries, and other neuromuscular conditions  CMS officials noted that patients with these conditions typically respond well to intensive rehabilitation therapy provided in a resource intensive inpatient hospital environment and to the specific interdisciplinary approach to care that is provided in the IRF setting  Stakeholders also noted that patients with spinal cord injuries, brain injuries, and other neuromuscular conditions may receive care in other settings  However, some stakeholders noted that some of these providers—such as skilled nursing facilities—generally do not offer the specialized care these patients generally require  Differences in payment systems and data limitations make it difficult to directly compare the attributes of Medicare beneficiaries discharged from the two qualifying hospitals and IRFs, including the costs of care they receive  Medicare uses separate payment systems to pay LTCHs and IRFs, for care provided to beneficiaries  LTCHs are paid pre-determined fixed amounts for care provided to Medicare beneficiaries, under the LTCH PPS  Medicare beneficiaries treated in LTCHs are assigned to diagnosis groups (MS-LTC-DRGs) for each stay—based on the patient’s primary and secondary diagnoses, age, gender, discharge status, and procedures performed  IRFs are also paid pre-determined fixed amounts for care provided to Medicare beneficiaries, but under a separate system—IRF PPS  Medicare beneficiaries treated in IRFs are assigned to case-mix groups—based on age, and level of motor and cognitive function—and then further assigned to one of four tiers (within these groups) based on the presence of specific comorbidities that may increase their cost of care  According to CMS officials, because the payment groups and assignments to those groups are different, it is difficult to directly compare LTCH patients, classified in diagnosis groups, with IRF patients, classified in case-mix groups  See Appendix II for more information on these payment systems  MedPAC has previously reported the differences in patient assessment tools used by post-acute care providers undermines Medicare’s ability to compare the patients admitted, costs of care, and outcomes beneficiaries achieve in these settings, on a risk-adjusted basis  MedPAC has also reported that while similar beneficiaries can receive care in each setting, payments can differ considerably for comparable conditions, due to differences in payment systems  It has made recommendations to address these issues  The Improving Medicare Post-Acute Care Transformation Act of 2014 also requires the Secretary of HHS to collect and analyze common patient assessment information and, in consultation with MedPAC, submit a report to Congress recommending a post-acute care PPS  Such efforts may make future comparison of beneficiaries, costs of services, and outcomes of care across these settings possible  While data limitations make a direct comparison difficult, based on our review of other data and information, and interviews with stakeholders, we identified similarities and differences between the qualifying hospitals and certain IRFs that provide specialty treatment for catastrophic spinal cord injuries, acquired brain injuries, or other paralyzing neuromuscular conditions  Key similarities and differences include the following: Volume of services  Our review of Medicare claims data, other information, and interviews with stakeholders indicate that—similar to the two qualifying hospitals—some IRFs treat a high volume (at least 100) of patients with complex spinal cord injury, brain injury, and other related conditions  Officials from the two qualifying hospitals, as well as some other stakeholders we interviewed—including officials from the Christopher & Dana Reeve Foundation and the Brain Injury Association of America—emphasized the importance of facilities treating a high volume of patients with these specialized conditions, which can be an indicator of expertise in treating these patients  Our review of Medicare claims data for 1,148 IRFs in fiscal year 2016 identified 21 IRFs that treated at least 100 Medicare beneficiaries with non-traumatic and traumatic spinal cord injuries and 109 IRFs that treated at least 100 Medicare beneficiaries with non-traumatic and traumatic brain injuries  Our review of Medicare claims data indicated that, similar to the two qualifying hospitals—some IRFs also treat a high volume of patients with “catastrophic” injuries—traumatic brain injury, traumatic spinal cord injury, and major multiple traumas with brain or spinal cord injuries  Specifically, we identified 25 IRFs that treated a high volume (at least 100) of Medicare beneficiaries with catastrophic injuries, in fiscal year 2016  In the absence of patient assessment data from the facilities, we did not independently evaluate the level and severity of these patients’ injuries, which can vary due to the presence of other co-morbid conditions  The Medicare case mix indexes we reviewed for these 25 IRFs indicated that, relative to other IRFs, most of these facilities treat patients who are more resource intensive  Specialty accreditation and designation as model systems  Like Shepherd Center, some IRFs receive CARF-accreditation for specialty programs to treat spinal cord and brain injuries  According to most stakeholders, this accreditation indicates expertise in treating these patients, as CARF International has established standards using evidence-based practices, among other factors  Officials from the two qualifying hospitals also noted CARF International has a specific focus on quality and outcomes  However, officials from Shepherd Center noted similarities in care and services offered at CARF-accredited facilities would depend on the specialties for which they are certified  Most of the stakeholders we interviewed also noted that designation as a NIDILRR model system is an indicator of similar expertise in treating patients with spinal cord and brain injuries  According to the Model Systems Knowledge Translation Center, spinal cord injury and brain injury model systems are recognized as national leaders in medical research and patient care and provide the highest level of comprehensive specialty services from the point of injury through eventual re-entry into full community life  While stakeholders we interviewed from NIDILRR model systems indicated the model system designation is focused primarily on research, rather than clinical care, most noted that model systems’ research often complements the facilities’ clinical efforts to address the unique needs of these patients  Officials from HHS’s Administration for Community Living also noted that all model system grantees must provide a continuum of care—emergency care, acute medical care, acute medical rehabilitation, and post-acute care—and that can happen in various provider types  According to officials from the qualifying hospitals and stakeholders from one other NIDILRR model system we interviewed, Craig Hospital and Shepherd Center are the only two LTCHs currently classified as spinal cord injury model systems; 12 of 14 spinal cord injury model systems are IRFs  Specialized programs and services  Similar to the two qualifying hospitals, some IRFs may also offer specialized programs and services for patients with brain and spinal cord injuries, but the availability of these programs and services may vary by facility  Officials from some of the IRFs that responded to our information request—which included both NIDILRR facilities and IRFs with CARF-accredited programs—told us they provide specialized programs and services for patients with similar conditions as those treated at two qualifying hospitals, and sometimes compete with the two qualifying hospitals for the same patients  For example, each IRF reported having interdisciplinary treatment teams; the capacity to provide medical management of medically complex and high acuity patients with spinal cord injury, traumatic brain injury, or other major multiple traumas associated with a brain or spinal cord injury; family education and training; and skin and wound programs or services, among other services  However, the availability of certain services—including but not limited to ventilator-dependent weaning programs, diaphragmatic pacing, and outpatient programs for spinal cord and traumatic brain injury patients—varied by facility  Staff with specialized training and clinical expertise  Similar to the two qualifying hospitals, most facilities that responded to our information request also reported having physicians, nurses, and physical and occupational therapists with specialty training in medical rehabilitation, spinal cord, and/or brain injury  However, the number of staff with these trainings, varied by facility  In comparison to the other facilities that responded to our information request, the number of nurses and physical and occupational therapists with these specialty trainings were generally higher at Craig Hospital and Shepherd Center  According to an American Spinal Injury Association consumer guideline that the Christopher & Dana Reeve Foundation typically provides to spinal cord injury patients and families, programs should regularly admit persons with spinal cord injury each year, to develop and maintain the necessary skills to manage a person with spinal cord injury, and a substantial portion of those admitted should have traumatic injuries  Out-of-state Admissions  Officials from the two qualifying hospitals emphasized they admit a significant number of patients from out-of-state, and our review of information provided by the qualifying hospitals and a select group of IRFs indicated the qualifying hospitals admit a higher percentage of patients from out-of-state  Specifically, information provided by these IRFs indicates that less than a quarter of patients admitted to these facilities, in 2016, were from out-of-state  Information provided by Craig Hospital and Shepherd Center indicate that about half of their patients were admitted from out-of-state in 2016  Officials from the Colorado Department of Health Care Policy & Financing also noted Craig Hospital treats a higher percentage of out-of-state patients, compared to IRFs in the state  Ability to treat medically complex patients  Officials from the two qualifying hospitals told us they treat more medically complex patients and provide a more complete range of medical services to spinal cord and brain injury patients, not provided by most IRFs  Specifically, officials from the two qualifying hospitals both noted they are able to treat patients much sooner in their recovery process than most IRFs, due to their LTCH status  Officials from the Shepherd Center noted that they have a 10-bed intensive care unit which allows them to take patients with certain injures that some IRFs may not be equipped to admit—such as patients requiring advance medical management and advanced level procedural services and monitoring  Information provided by Shepherd Center indicated that, in calendar year 2017, approximately 20 percent of all inpatients were admitted to this unit and 13 percent of all inpatients were internally transferred to this unit after developing medical complications  According to officials, Craig Hospital does not have an intensive care unit, but noted their ability to similarly care for medically complex patients—including telemetry (e g , specialized heart monitoring) and one-to-one nursing care, if necessary  Most stakeholders we interviewed agreed that both qualifying hospitals’ LTCH status provides certain advantages over IRFs, such as the ability to admit some medically complex patients earlier in the recovery process and longer lengths of stay  Stakeholders from most of the IRFs we interviewed also reported having the flexibility to admit some medically complex patients requiring more advanced level monitoring and resources earlier in the recovery process—such as patients with disorders of consciousness  Officials from the two qualifying hospitals also said they offer a continuum of care that can meet patient’s changing needs, without the need to transfer them to different facilities  Information provided by Craig Hospital indicated that 83 percent of patients treated at its facility, in 2016, were discharged to home, 13 percent were discharged to another post-acute care facility, and 3 percent were discharged to an acute care hospital  In 2016, approximately 91 percent of patients treated at Shepherd Center were discharged to home, 7 percent were discharged to another post- acute care facility, and 2 percent were discharged to an acute care hospital  Information provided by the IRFs that responded to our written request varied by facility, but—similar to the two qualifying hospitals— each facility discharged more than 65 percent of patients to home  IRF payment criteria  CMS and most other stakeholders we interviewed noted that two Medicare payment policies applicable to IRFs, but not LTCHs, may contribute to their different patient populations  Specifically, to be classified for payment under Medicare’s IRF PPS, at least 60 percent of the IRF’s total inpatient population must require intensive rehabilitative treatment for one or more of 13 conditions—which includes both spinal cord and brain injury  To be admitted to an IRF, Medicare beneficiaries must reasonably be expected to actively participate in and benefit from the intensive rehabilitation therapy program, typically provided in IRFs  According to HHS, per industry standard, the intensive rehabilitation therapy program is often demonstrated by providing three hours of rehabilitation services per day for at least five days per week, but this is not the only way such intensity can be demonstrated  Officials from the two qualifying hospitals told us they generally use Medicare’s intensive rehabilitation requirement as a minimum standard for their rehabilitation patients—even though they are not held to this requirement, for the purposes of Medicare payment—but noted that some of their patients may not meet this requirement, due to their medical complexity  Length of stay and site-neutral payment requirements, for LTCHs  As previously noted, LTCHs—including the two qualifying hospitals—must have an average length of stay of greater than 25 days; IRFs are not subject to this requirement  The average length of stay for patients discharged from the Craig Hospital was about 60 days, in fiscal year 2016, and the average length of stay for patients discharged from Shepherd Center was about 53 days, in calendar year 2016  Stakeholders from the IRFs that responded to our information request reported average lengths of stay ranging from 14 to 31 days, for patients discharged in fiscal year 2016; the ranges of lengths of stay were slightly higher for spinal cord injury and traumatic brain injury inpatients for the IRFs, during the same period  LTCHs are also generally subject to site- neutral payment policy that is not applicable to IRFs and may decrease LTCHs payments for certain discharges, under Medicare  Other services provided  In addition to these Medicare specific differences, a few stakeholders we interviewed also noted the two qualifying hospitals receive additional funding from their strong philanthropic donor base that may allow them to provide other services and resources, not covered by Medicare or offered at some IRFs  For example, while a few IRFs that responded to our information request reported offering housing for families of injured patients, the two qualifying hospitals offer up to 30 days of free housing to families of newly injured rehabilitation patients, if both the family and patient live more than 60 miles from the hospital  Officials from Shepherd Center told us their revenues are supplemented by investment income and donor funds  Craig Hospital has also established a foundation that supports the hospital in achieving its goals through philanthropy  We provided a draft of this report to HHS  HHS provided technical comments, which we incorporated as appropriate  We also provided the two qualifying hospitals summaries of information we collected from them, to confirm the accuracy of statements included in our draft report  We incorporated their comments, as appropriate  We are sending copies of this report to the Secretary of Health and Human Services and other interested parties  In addition, the report will be available at no charge on GAO’s website at http://www gao gov  If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at farbj@gao gov  Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report  Other major contributors to this report are listed in appendix IV  This appendix describes our methodology for conducting simulations of payments for the two qualifying hospitals  We used Medicare claims data to conduct simulations of payments for the two qualifying hospitals  We first identified discharges at each hospital in two baseline years—federal fiscal years 2013 and 2016  We selected fiscal year 2016 because it was the year with the most recent data available at the time of our analysis, and we selected a second baseline year because data for 2016 was different than data for other recent years  For example, the number of discharges for one qualifying hospital declined by nearly half between fiscal years 2013 and 2016  We chose fiscal year 2013 because data from that year was used to help determine which hospitals are subject to the temporary exception  To identify how to appropriately calculate the long-term care hospital (LTCH) payment for each of these discharges in future payment years, we reviewed applicable federal regulation and documents from the Centers for Medicare & Medicaid Services (CMS) and the Medicare Payment Advisory Commission (MedPAC), and interviewed officials from both organizations  See table 4 for the relevant components in the formulas, such as Medicare severity long-term care diagnosis related group (MS-LTC-DRG) weights, identified from final rule tables  When conducting these simulations, we made the following assumptions: For simulated payments for payment policies in effect for fiscal years 2017 and 2018, we used the base rates, relative weights (e g , the MS-LTC-DRG weights), geometric mean length of stay, wage index, geographic adjustment factor, fixed-loss amounts, and outlier thresholds that were published in the final rule tables for LTCH and inpatient prospective payment system (IPPS) hospitals—also known as acute care hospitals—for each respective year  At the time we began our analysis, this information was not known for fiscal years 2019 through 2021  We chose to use the fiscal year 2018 rates when conducting simulations for payment policies in those years because historical trends showed that annual changes were minimal—about 1 percent  Therefore, to the extent that these values continue to change over time, our findings may understate or overstate the amount that the qualifying hospitals would have been paid in our baseline years based on these future payment policies  The site-neutral payment policy did not apply to discharges from the fiscal year 2013 baseline year  Therefore, we examined Medicare claims data to determine whether each discharge would have met the criteria to receive the LTCH standard rate in that year  Specifically, we determined whether each discharge had an acute care hospital stay that immediately preceded their LTCH stay  We then determined whether the time at the acute care hospital included three or more days in the intensive care unit or whether there was a code on the LTCH claim that indicated at least 96 hours of mechanical ventilation services were provided  Per Medicare’s payment policy, we assumed any discharge that met these two criteria would qualify for full LTCH payment rate, unless the case was a psychiatric or rehabilitation stay, as identified by the following MS-LTC-DRG codes: 876, 880, 881, 882, 883, 884, 885, 886, 887, 894, 895, 896, 897, 945, or 946  Under statute, unless 50 percent or more of the hospital’s discharges beginning during or after 2020 qualify for the standard rate, no subsequent payments will be made to a hospital at that rate  Therefore, when calculating simulated payments for fiscal year 2021, we applied the 50 percent threshold  At the time of our analysis, CMS had not yet finalized this policy through rule-making  As of November 2018, CMS officials told us that it is unlikely that any payment adjustment under this provision would apply until 2022 because the percentage cannot be determined until after an LTCH’s cost reporting period has ended and data have been submitted  Shepherd Center’s fiscal year is different than the federal fiscal year  Therefore, the variables used to determine whether discharges in federal fiscal year 2016 met criteria to receive the standard rate were not available to use for some of the discharges that year  Of those discharges, we assumed that the same percentage of discharges that met the criteria to receive the standard rate in Shepherd’s fiscal year—30 percent—met the criteria in federal fiscal year 2016  When calculating site-neutral payments, we assumed that each discharge would be paid at a rate comparable to that for acute care hospitals—the IPPS comparable amount rate  Site-neutral payments may also be based on the estimated cost-of-care, if it is lower than the IPPS comparable amount rate  However, over 90 percent of discharges at the qualifying hospitals were paid at the IPPS comparable amount rate in fiscal year 2016  Per CMS’s recommendation, we applied the cost-to-charge ratio that was effective October 1, 2017, for each qualifying hospital, regardless of discharge date  For Craig Hospital this value was 0 442 and for Shepherd Center this value was 0 464  According to CMS officials, in general, these values do not change significantly when they are updated during the fiscal year  Therefore, they believe that using the values effective at the start of the fiscal year is a reasonable assumption  We excluded indirect medical education adjustments and disproportionate share hospital payments that are part of the IPPS comparable amount rate because, according to CMS, they were unlikely to have much impact for these hospitals  CMS reviewed each of these assumptions and agreed they were reasonable for purposes of our analysis  CMS also verified that we were correctly applying the formulas for calculating these payments and using the appropriate values from the final rules  Figures 3 and 4 illustrate the methodology for calculating Medicare payments under the long-term care hospital (LTCH) prospective payment system (PPS) and the inpatient rehabilitation facility (IRF) PPS, respectively, as reported by the Medicare Payment Advisory Commission (MedPAC)  Appendix III: List of Common Diagnosis Groups for Long-Term Care Hospitals (LTCH) In its March 2018 annual report to the Congress, the Medicare Payment Advisory Commission (MedPAC) reported that 20 diagnosis groups accounted for over 61 percent of LTCH discharges at both for-profit and not-for-profit facilities, in fiscal year 2016  Table 5 provides a list of these 20 diagnosis groups  In addition to the contact named above, Will Simerl, Assistant Director; Kathy King; Amy Leone, Analyst-in-Charge; Todd Anderson; Sam Amrhein; LaKendra Beard; Rich Lipinski; Jennifer Rudisill; and Eric Wedum made key contributions to this report  Also contributing were Leia Dickerson, Diona Martyn, Vikki Porter, and Lisa Rogers 
Report 2:  These centers, which can shelter as many as 20 youth, are generally supposed to be located in areas that are frequented or easily reached by runaway and homeless youth  BCP grantees must make efforts to contact the parents and relatives of runaway and homeless youth  Grantees are also required to establish relationships with law enforcement, health and mental health care, social service, welfare, and school district systems to coordinate services  Grantees maintain confidential statistical records of youth, including youth who are not referred to out-of-home shelter services  Further, grantees are required to submit an annual report to HHS detailing the program activities and the number of youth participating in such activities, as well as information about the operation of the centers  BCP grants are allocated directly to grantees for a three-year period  Funding is generally distributed to entities based on the proportion of the nation's youth under age 18 in the jurisdiction where the entities are located  The 50 states, the District of Columbia, and Puerto Rico each receive a minimum allotment of $200,000  Separately, the territories (currently, this includes American Samoa and Guam) each receive a minimum of $70,000  The amount of funding for each state or territory can further depend on whether grant applicants in that jurisdiction applied for funding, and if so, whether the applicant fulfilled the requirements in the authorizing law and grant application  For example, the authorizing law directs HHS to give priority to applicants who have demonstrated experience in providing services to runaway and homeless youth  HHS is to re-allot any funds designated for grantees in one state to grantees in other states that will not be obligated before the end of a fiscal year  See Table A-1 for the amount of funding allocated for each state in FY2017 and FY2018  The costs of the BCP are shared by the federal government (90%) and grantees (10%)  In FY2008, HHS began funding a three-year Rural Host Homes Demonstration Project , which was initiated to expand BCP shelter and support services to runaway and homeless youth who live in rural areas not served by shelter facilities  The project supported grantees that provided youth with shelter (via host home families who were recruited, screened, and trained) and preventive services, including transportation, counseling, educational assistance, and aftercare planning, among others  Over the course of the three years, the project served 781 youth, 411 of whom received shelter and 370 of whom received preventive services without shelter  Recognizing the difficulty that youth face in becoming self-sufficient adults, the Transitional Living Program provides longer-term shelter and assistance for youth ages 16 through 22 (or older if the youth entered the TLP prior to reaching age 22) who may leave their biological homes due to family conflict, or have left and are not expected to return home  Pregnant and/or parenting youth are eligible for TLP services  In FY2017, the TLP provided services to 3,517 youth  In FY2018, the program funded 229 organizations  Each TLP grantee may shelter up to 20 youth at various sites, such as host family homes, supervised apartments owned by a social service agency, scattered-site apartments, or single-occupancy apartments rented directly with the assistance of the grantee  Youth may remain at TLP sites for up to 540 days (18 months), or longer for youth under age 18  Youth ages 16 through 22 may remain in the program for a continuous period of 635 days (approximately 21 months) under "exceptional circumstances " This term means circumstances in which a youth would benefit to an unusual extent from additional time in the program  A youth in a TLP who has not reached age 18 on the last day of the 635-day period may, in exceptional circumstances and if otherwise qualified for the program, remain in the program until his or her 18 th birthday  Youth receive several types of services at TLP-funded programs: basic life-skills training, including consumer education and instruction in budgeting and the use of credit; parenting support and child care (as appropriate); building interpersonal skills; educational opportunities, such as GED courses and postsecondary training; assistance in job preparation and attainment; and mental and physical health care services  TLP grantees are required to develop a written plan designed to help youth transition to living independently or another appropriate living arrangement, and they are to refer youth to other systems that can help to meet their educational, health care, and social service needs  The grantees must also submit an annual report to HHS that includes information regarding the activities carried out with funds and the number and characteristics of the homeless youth  As part of the FY2002 budget request, the George W  Bush Administration proposed a $33 million initiative to fund maternity group homes—or centers that provide shelter to pregnant and parenting teens who are vulnerable to abuse and neglect—as a component of the TLP  Although the TLP authorized services for pregnant and parenting teens prior to FY2002, the Bush Administration sought funds specifically to serve this population  Increased funds were ultimately provided to enable these youth to access TLP services  The 2003 amendments to the Runaway and Homeless Youth Act ( P L  108-96 ) provided explicit authority to use TLP funds for this purpose  Since FY2004, funding for adult-supervised transitional living arrangements that serve pregnant or parenting women ages 16 to 21 and their children has been awarded to organizations that receive TLP grants  These organizations provide youth with parenting skills, including child development education, family budgeting, health and nutrition, and other skills to promote family well-being  TLP grants are distributed competitively by HHS to community-based public and private organizations throughout the country for a five-year period  Grantees must provide at least 10% of the total cost of the program  HHS is carrying out a study to learn more about the long-term outcomes of 1,250 youth who have used TLP services  The study seeks to describe the outcomes and to isolate and describe promising practices and other factors that may contribute to their successes or challenges  Of particular interest for the study is how services are delivered, the demographics of youth, and their socio-emotional wellness and life experiences  It involves both a process evaluation and impact evaluation, with youth randomly assigned to the treatment (i e , participation in the TLP) and control groups  The study seeks to address the following questions: (1) How do TLP programs operate, what types of program models are used to deliver services, and what services are delivered to homeless youth? (2) What are the long-term housing outcomes and protective factors for youth who participate in the TLP program immediately, six months, 12 months, and 18 months after exiting the program? (3) What interventions can be attributed to any positive outcomes experienced by youth who participate in the TLP? According to HHS, the pilot study revealed challenges "in collecting data from a large enough sample size of youth to detect any effects so that conclusions could be drawn about the impact of homeless youth served by TLPs " HHS is not certain how it will move forward with the study  In FY2016, HHS began the Transitional Living Program Special Population Demonstration project  The project funded nine grantees over a two-year period that tested approaches for serving populations that need additional support: LGBTQ runaway and homeless youth ages 16 to 21; and young adults who have left foster care because of emancipation  Grantees were expected to provide strategies that help youth build protective factors, such as connections with schools, employment, and appropriate family members and other caring adults  According to HHS, a process evaluation will assess how grantees are implementing the demonstration project  HHS separately funded a project from FY2012 through FY2014 to build the capacity of TLPs in serving LGBTQ youth  Known as the 3/40 Blueprint: Creating the Blueprint to Reduce LGBTQ Youth Homelessness , the purpose of the grant was develop information about serving the LGBTQ youth population experiencing homelessness, such as through efforts to identify innovative intervention strategies, determine culturally appropriate screening and assessment tools, and better understand the needs of LGBTQ youth served by RHY providers  The website developed by the grantee, the University of Illinois at Chicago, identifies promising practices that serve LGBTQ youth who are experiencing homelessness and publishes information about their challenges  In FY2009, HHS began the Support Systems for Rural Homeless Youth Demonstration Project   Six states received grants to support TLPs in rural communities in serving young adults who have few or no connections to a supportive family structure or community resources  The five-year project sought to provide services across three main areas: survival support, which includes housing, health care (including mental health), and substance abuse treatment and prevention; community, which includes community service, youth and adult partnerships, mentoring, and peer support groups; and education and employment, which includes high school or GED completion, postsecondary education, and job training and employment  The six states—Colorado, Iowa, Minnesota, Nebraska, Oklahoma, and Vermont—each received annual grants of $200,000  According to HHS, all of the sites engaged youth in positive youth development activities that included safe places for youth to go  In addition, they raised awareness about homelessness in rural areas and addressed some of the unique needs around employment, housing, and transportation  However, the sites also confirmed that there is a general lack of available housing for homeless youth and that transportation was the most critical impediment to serving these youth  The Street Outreach Program provides runaway and homeless youth living on the streets or in areas that increase their risk of using drugs or being subjected to sexual abuse, prostitution, sexual exploitation, and trafficking are eligible to receive services  The program's goal is to assist youth in transitioning to safe and appropriate living arrangements  SOP services include the following: treatment and counseling; crisis intervention; drug abuse and exploitation prevention and education activities; survival aid; street-based education and outreach; information and referrals; and follow-up support  Grants are awarded for a three-year period, and grantees must provide 10% of the funds to cover the cost of the program  In FY2018, 96 grantees were funded  In FY2017 grantees made contact with 24,366 youth  The Family and Youth Services Bureau initiated the Street Outreach Program Data Collection Project in 2012 to learn more about the lives and needs of homeless and runaway youth served by SOP grantees  The purpose of the project was to design services to better meet the needs of these youth  FYSB collected information through focus groups and computer-assisted personal interviews with 656 youth (ages 14 to 21 years) served by grantees in 11 cities  The project found that participants were homeless on average for nearly two years and had challenges with substance abuse, mental health, and exposure to trauma  Youth most identified that they were in need of job training or help finding a job, transportation assistance, and clothing  The top barriers to obtaining shelter were shelters being full, not knowing where to go for shelter, and lacking transportation to get to a shelter  The study researchers concluded that more emergency shelters could help prevent youth from sleeping on the street  Further, they noted that youth on the streets need more intensive case management (e g , careful assessment and treatment planning, linkages to community resources, etc ) and more intensive interventions  HHS funds the Runaway and Homeless Youth Training and Technical Assistance Center (RHYTTAC) to provide technical assistance to RHYP grantees  HHS awarded a five-year cooperative agreement, from September 30, 2017, through September 29, 2020, to National Safe Place to operate RHYTTAC  National Safe Place is a national youth outreach program that aims to educate young people about the dangers of running away or trying to resolve difficult, threatening situations on their own  RHYTTAC is designed to provide training and conference services to RHYP grantees that enhance and promote continuous quality improvement to services provided by RHYP grantees  Further, RHYTTAC offers resources and information through its website, tip sheets, a quarterly newsletter, toolkits, sample policies and procedures, and other resources  RHYTTAC also provides assistance to individual grantees in response to their questions or concerns, as well as concerns raised by HHS as part of the Runaway and Homeless Youth Program Monitoring System (see subsequent section)  A portion of the funds for the BCP, TLP, and related activities are allocated for a national communications system known as the National Runaway Safeline ("Safeline")  The Safeline is intended to help homeless and runaway youth (or youth who are contemplating running away) through counseling, referrals, and communicating with their families  Beginning with FY1974 and every year after, the Safeline, which until 2013 was called the National Runaway Switchboard, has been funded through the Basic Center Program grant or the Consolidated Runaway and Homeless Youth Program grant  The Safeline is located in Chicago and operates each day to provide services to youth and their families across the country  Services include (1) a channel through which runaway and homeless youth or their parents may leave messages; (2) 24-hour referrals to community resources, including shelter, community food banks, legal assistance, and social services agencies; and (3) crisis intervention counseling to youth  In calendar year 2017, the Safeline handled nearly 30,000 contacts with youth (via phone, computer, emails, and postings), of which nearly three-quarters were from youth and 9% were from parents; the other callers were relatives, friends, and others  Other services are also provided through the Safeline  Since 1995, the "Home Free" family reunification program has provided bus tickets for youth ages 12 to 21 to return home or to an alternative placement near their home through Home Free  HHS evaluates each RHYP grantee through the Runaway and Homeless Youth Monitoring System  Staff from regional ACF offices and other grant recipients (known as peer reviewers) inspect the program site, conduct interviews, review case files and other agency documents, and conduct entry and exit conferences  The monitoring team then prepares a written report that identifies the strengths of the program and areas that require corrective action  The Reconnecting Homeless Youth Act of 2008 required that within one year of its enactment (October 8, 2009), HHS was to issue rules that specified performance standards for public and nonprofit entities that receive BCP, TLP, and SOP grants  On April 14, 2014, HHS issued a notice of proposed rulemaking (NPRM) for the new performance standards and other requirements for the Runaway and Homeless youth program grantees  On December 20, 2016, HHS implemented a final rule that was similar to the provisions in the NPRM  These standards are used to monitor individual grantee performance  The Senate Committee on Health, Education, Labor, and Pensions (HELP) and the House Committee on Education and Labor have exercised jurisdiction over the Runaway and Homeless Youth Program  HHS must submit reports biennially to the committees on the status, activities, and accomplishments of program grant recipients and evaluations of the programs performed by HHS  The most recent report was submitted in January 2018, and covered FY2014 and FY2015  The 2003 reauthorization law ( P L  108-96 ) of the Runaway and Homeless Youth Act required that HHS, in consultation with the U S  Interagency Council on Homelessness, submit a report to Congress on the promising strategies to end youth homelessness within two years of the reauthorization, in October 2005  The report was submitted to Congress in June 2007  As mentioned above, the 2008 reauthorization law ( P L  110-378 ) required HHS, as of FY2010, to periodically submit to Congress an incidence and prevalence study of runaway and homeless youth ages 13 to 26, as well as the characteristics of a representative sample of these youth  As discussed, Congress appropriated funding to HUD for this purpose and the study, known as Voices of Youth Count , includes multiple publications about its findings  The 2008 law also directed the Government Accountability Office (GAO) to evaluate the process by which organizations apply for BCP, TLP, and SOP, including HHS's response to these applicants  GAO submitted a report to Congress in May 2010 on its findings  GAO found weaknesses in several of the procedures for reviewing grants, such as that peer reviewers for the grant did not always have expertise in runaway and homeless youth issues and feedback on grants was not provided in a permanent record  In addition, GAO found that HHS delayed telling successful grantees that the grant had been awarded to them  HHS has implemented the recommendations made in the report  Appendix A  Basic Center Program (BCP) Funding Appendix B  Additional Federal Support for Runaway and Homeless Youth Since the creation of the Runaway and Homeless Youth Program, other federal initiatives have also established services for such youth  Youth Homelessness Demonstration Program (YHDP): The omnibus appropriations laws for FY2016 through FY2018 enabled HUD to set aside up to $33 million (FY2016), $43 million (FY2017), and $80 million (FY2018) from the Homeless Assistance Grants account to implement projects that demonstrate how a "comprehensive approach" can "dramatically reduce" homelessness for youth through age 24  The appropriations laws each fiscal year direct this funding to up to 10 communities with the FY2016 funding; up to 11 communities with the FY2017 funding, including at least five rural communities; and up to 25 communities with the FY2018 funding, including at least eight rural communities  HUD has allocated $33 million to 10 communities for FY2016 and $43 million for FY2017  In addition, HUD is taking steps to evaluate the YHDP grantee communities in developing and carrying out a coordinated community approach to preventing and ending youth homelessness  100-Day Challenges to End Youth Homelessness : Since 2016, cities have partnered with public and private entities to accelerate efforts to prevent and end youth homelessness  A Way Home America and Rapid Results Institute, organizations that focus on pressing social problems, have provided support to the organizations  HHS provided training and technical assistance through RHYTTAC to the first three cities involved in the challenge: Los Angeles, CA; Cleveland, OH; and Austin, TX  In general, participating communities have housed homeless youth and have identified new housing options for this population  Youth with Child Welfare Involvement At-Risk of Homelessness (YAHR): HHS has funded grants to build evidence on what works to prevent homelessness among youth and young adults who have child welfare involvement  HHS awarded funds to 18 grantees for a two-year planning period (2013-2015)  Six of the grantees received additional funding to refine and test their service models during a second phase (2015-2018)  A subset of those grantees will then be selected to conduct a rigorous evaluation of their impact on homelessness  In school year 2016-2017, more than 1 3 million children and youth were homeless  Of these students, over 118,000 were homeless youth unaccompanied by their families  The Department of Education administers the Education for Homeless Children and Youth program, which was established under the McKinney-Vento Homeless Assistance Act of 1987 ( P L  100-77 ), as amended  This program assists state education agencies (SEAs) to ensure that all homeless children and youth have equal access to the same, appropriate education, including public preschool education, that is provided to other children and youth  Grants made by SEAs to local education agencies (LEAs) under this program must be used to facilitate the enrollment, attendance, and success in school of homeless children and youth  Program funds may be appropriated for activities such as tutoring, supplemental instruction, and referral services for homeless children and youth, as well as providing them with medical, dental, mental, and other health services  McKinney-Vento liaisons for homeless children and youth in each LEA is responsible for coordinating activities for these youth with other entities and agencies, including local Basic Center and Transitional Living Program grantees  States that receive McKinney-Vento funds are prohibited from segregating homeless students from non-homeless students, except for short periods of time for health and safety emergencies or to provide temporary, special, supplemental services  FY2019 funding for the program is $93 5 million  According to a 2017 survey of 43,000 college students at selected colleges and universities, 9% of those attending four-year universities and 12% of those attending community college had been homeless in the last year  In addition, 37% of university students and 46% of community college students were housing insecure in the past year, meaning that they had difficulty paying rent or lived with others beyond the expected capacity of the housing, among other scenarios  The Higher Education Act (HEA) authorizes financial aid and support programs that target homeless students and other vulnerable populations  For purposes of applying for federal financial aid, a student's expected family contribution (EFC) is the amount that can be expected to be contributed by a student and the student's family toward his or her cost of education  Certain groups of students are considered "independent," meaning that only the income and assets of the student (and not their parents or guardians) are counted  Individuals under age 24 who have been verified during the school year as either (1) unaccompanied and homeless or (2) unaccompanied, self-supporting, and risk of homelessness  This verification can come from a McKinney-Vento liaison for homeless children and youth in the local education agency; the director (or designee) of a program funded under the Runaway and Homeless Youth program; the director (or designee) of an emergency shelter or transitional housing program funded by HUD; or a financial aid administrator  Separately, HEA provides that homeless children and youth are eligible for what are collectively called the federal TRIO programs  This includes the following TRIO programs: Talent Search, Upward Bound, Student Support Services, and Educational Opportunity Centers  The TRIO programs are designed to identify potential postsecondary students from disadvantaged backgrounds, prepare these students for higher education, provide certain support services to them while they are in college, and train individuals who provide these services  HEA directs the Department of Education (ED), which administers the programs, to (as appropriate) require applicants seeking TRIO funds to identify and make services available, including mentoring, tutoring, and other services, to these youth  TRIO funds are awarded by ED on a competitive basis  In addition, HEA authorizes services for homeless youth through TRIO Student Support Services—a program intended to improve the retention and graduation rates of disadvantaged college students—that include temporary housing during breaks in the academic year  In FY2019, TRIO appropriations are $1 1 billion  Separately, HEA allows additional uses of funds through the Fund for the Improvement of Postsecondary Education (FIPSE) to establish demonstration projects that provide comprehensive support services for students who are or were homeless at age 13 or older  FIPSE is a grant program that seeks to support the implementation of innovative educational reform ideas and evaluate how well they work  As specified in the law, the projects can provide housing to the youth when housing at an educational institution is closed or unavailable to other students  FY2019 appropriations for FIPSE are $5 million  Recently emancipated foster youth are vulnerable to becoming homeless  In FY2017, nearly 20,000 youth "aged out" of foster care  The Chafee Foster Care Independence Program (CFCIP), created under the Chafee Foster Care Independence Act of 1999 ( P L  106-169 ), provides states with funding to support children and youth ages 14 to 21 who are in foster care and former foster youth ages 18 to 21 (and up to age 23 in states that extend foster care to age 21)  States are authorized to receive funds based on their share of the total number of children in foster care nationwide  However, the law's "hold harmless" clause precludes any state from receiving less than the amount of funds it received in FY1998 or $500,000, whichever is greater  The program specifies funding for transitional living services, and as much as 30% of the funds may be dedicated to room and board  The program is funded through mandatory spending, and as such $140 million ($143 million as of FY2020) is provided for the program each year through the annual appropriations process  The Family Violence Prevention and Services Act (FVPSA), Title III of the Child Abuse Amendments of 1984 ( P L  98-457 ), authorized funds for Family Violence Prevention and Service grants that work to prevent family violence, improve service delivery to address family violence, and increase knowledge and understanding of family violence  From FY2007 to FY2009, one of these projects focused on runaway and homeless youth in dating violence situations through HHS's Domestic Violence/Runaway and Homeless Youth Collaboration on the Prevention of Adolescent Dating Violence initiative  The initiative was created because many runaway and homeless youth come from homes where domestic violence occurs and may be at risk of abusing their partners or becoming victims of abuse  The initiative funded eight states and community-based organizations to address the issue of teen dating violence among runaway and homeless youth  The grants funded activities such as curriculum on dating violence, small groups for teens, and a sexual assault/dating violence reduction program  The initiative resulted in an online toolkit for advocates in the runaway and homeless youth and domestic and sexual assault fields to help programs better address relationship violence with runaway and homeless youth 

ground_truth: The Centers for Medicare & Medicaid Services pays LTCHs for care provided to Medicare beneficiaries. There were about 400 LTCHs across the nation in 2016. The 21st Century Cures Act included a provision for GAO to examine certain issues pertaining to LTCHs. This report examines (1) the health care needs of Medicare beneficiaries who receive services from the two qualifying hospitals; (2) how Medicare LTCH payment polices could affect the two qualifying hospitals; and (3) how the two qualifying hospitals compare with other LTCHs and other facilities that may treat Medicare patients with similar conditions. GAO analyzed the most recently available Medicare claims and other data for the two qualifying hospitals and other facilities that treat patients with spinal cord injuries. GAO also interviewed HHS officials and stakeholders from the qualifying hospitals, other facilities that treat spinal cord patients, specialty associations, and others. GAO provided a draft of this report to HHS. HHS provided technical comments, which were incorporated as appropriate. We also provided the two qualifying hospitals summaries of information we collected from them, to confirm the accuracy of statements included in our draft report. We incorporated their comments, as appropriate. Spinal cord injuries may result in secondary complications that often lead to decreased functional independence and quality of life. The 21st Century Cures Act changed how Medicare pays certain long-term care hospitals (LTCH) that provide spinal cord specialty treatment. For these hospitals, the act included a temporary exception from how Medicare pays other LTCHs. Two LTCHs—Craig Hospital in Englewood, Colorado and Shepherd Center in Atlanta, Georgia—have qualified for this exception. GAO found that most Medicare beneficiaries treated at these two hospitals typically receive specialized care for multiple chronic conditions and other long-term complications that develop after initial injuries, such as pressure ulcers that can result in life-threatening infection. The two hospitals also provide specialty care for acquired brain injuries, such as traumatic brain injuries. GAO's simulations of Medicare payments to these two hospitals using claims data from two baseline years—fiscal years 2013 and 2016—illustrate potential effects of payment policies. LTCHs are paid under a two-tiered system for care provided to beneficiaries: they receive the LTCH standard federal payment rate—or standard rate—for certain patients discharged from the LTCH, and a generally lower rate—known as a “site-neutral” rate—for all other discharges. Under the temporary exception, Craig Hospital and Shepherd Center receive the standard rate for all discharges during fiscal years 2018 and 2019. Assuming their types of discharges remain the same as in fiscal years 2013 and 2016, GAO's simulations of Medicare payments in the baseline years indicate: Most of the discharges we examined would not qualify for the standard rate, if the exception did not apply. Medicare payments would generally decrease under fiscal year 2020 payment policy, once the exception expires. However, the actual effects of Medicare's payment policies on these two hospitals could vary based on factors, including the severity of patient conditions (e.g., Medicare payment is typically higher for more severe injuries), and whether hospitals' discharges meet criteria for the standard rate. Similarities and differences may exist between the two qualifying hospitals and other facilities that treat Medicare patients with spinal cord and brain injuries. Patients with spinal cord and brain injuries may receive care in other LTCHs, but GAO found that most Medicare beneficiaries at these other LTCHs are treated for conditions other than spinal cord and brain injuries. Certain inpatient rehabilitation facilities (IRF) also provide post-acute rehabilitation services to patients with spinal cord and brain injuries. While data limitations make a direct comparison between these facilities and the two qualifying hospitals difficult, GAO identified some similarities and differences. For example, officials from some IRFs we interviewed reported providing several of the same programs and services as the two qualifying hospitals to medically complex patients, but the availability of services and complexity of patients varied. Among other reasons, the different Medicare payment requirements that apply to LTCHs and IRFs affect the types of services they provide and the patients they treat.