Energy Employees Compensation: Labor Could Better Assist Claimants through Clearer Communication

For decades, Energy, its predecessor agencies, and contractors employed thousands of employees in hazardous work in nuclear weapons production, exposing many employees to toxic substances. The Energy Employees Occupational Illness Compensation Program, administered by DOL, provides compensation for illnesses linked to exposures. Since 2004, DOL has provided about $4.4 billion to eligible employees and their survivors.

GAO was asked to review aspects of the claims process for contracted employees. GAO examined (1) the number and outcome of compensation claims for illnesses resulting from exposure to toxins that DOL has reopened since 2012, and (2) the Advisory Board's advice to DOL on the scientific soundness of its database on toxins and illnesses, and DOL's responses. GAO analyzed DOL claims data for 2012—when a new data system was introduced— through 2017 and assessed their reliability. GAO reviewed relevant federal laws and DOL procedures, and Advisory Board documents and interviewed DOL officials, Advisory Board members, experts, and a claimant advocate.

The Department of Labor (DOL), from 2012 through 2017, reopened more than 7,000 compensation claims by contracted workers with illnesses resulting from exposure to toxins at Department of Energy (Energy) worksites. Of these reopened claims, 69 percent were approved for compensation (see figure). Claims can be reopened for various reasons, including new information on toxic substances and associated illnesses or new evidence provided by a claimant. According to DOL's Office of the Ombudsman officials, some claims may have been denied as a result of claimants not understanding the evidence required to support their claim. Moreover, the Ombudsman's two most recent reports in 2015 and 2016 found DOL's letters to claimants requesting additional evidence or informing them of the final decision did not clearly explain the specific evidence needed or why previously submitted evidence was deemed insufficient. GAO's previous work also found deficiencies in the quality of a sample of DOL's written communication with claimants. DOL has provided training to claims examiners on how to write clearly in correspondence and plans to assess the training. The assessment is an opportunity for DOL to better understand why some claimants remain confused about needed evidence and could help DOL target its training resources more effectively.

The Advisory Board on Toxic Substances and Worker Health (Advisory Board) recommended in 2016 and 2018 that DOL incorporate additional sources of information on toxic substances and associated illnesses into the database it uses to help determine eligibility for claims compensation. While DOL noted that certain additional data sources might be useful, it has not added all of the recommended data sources. The Advisory Board was created to provide technical advice to DOL on its database, among other things.

GAO recommends that DOL ensure any assessment of its staff training efforts considers claimants' challenges with understanding DOL's communications on evidence for claims. DOL neither agreed nor disagreed with the recommendation except to note that it plans to focus its training on such topics as quality of written communications and assess its training efforts.

For many decades, and as recently as the 1960s, the Department of  Energy (Energy), its predecessor agencies, and its contractors have  employed thousands of individuals in secretive and potentially dangerous  work associated with nuclear weapons production. Many workers were  unknowingly exposed to toxic substances, including radioactive and  hazardous materials, and subsequently developed serious illnesses. To  provide compensation to these workers, the Energy Employees  Occupational Illness Compensation Program Act of 2000 (EEOICPA) was  enacted. The Department of Labor’s (DOL) Division of Energy  Employees Occupational Illness Compensation, within the Office of  Workers’ Compensation Programs, has primary responsibility for  administering Parts B and E of this legislation, as amended, with  assistance from several other federal agencies. The Part E program,  which is the focus of this review, provides financial compensation to  employees of Energy contractors and subcontractors, as well as their  survivors, for wage loss, impairments, and medical expenses resulting  from work-related illnesses linked to exposure to toxic substances. Since  the creation of Part E in 2004, over 135,000 claims have been filed and  DOL has paid about $4.4 billion on over 54,000 claims.

Contracted workers who believe they may have been exposed to a toxic  substance related to their employment at an Energy worksite and have  become ill may submit a claim and supporting documentation, thereby  initiating an adjudication process resulting in the claim’s approval or  denial. However, even after this decision has been reached, a claimant  may request that DOL reopen his or her claim under Part E, if the  claimant can submit new evidence or identify a change in a relevant  program policy. For example, new evidence can emerge related to a  claimant’s exposure to a toxic substance, or to the relationship of a  particular toxic substance to a particular illness. If a claim is reopened, the  available evidence is reviewed through the adjudication process and  results in an approval or denial of the reopened claim. Little is known  about the outcomes of reopened claims.

To assist the claims adjudication process, DOL has developed an online  database, known as the Site Exposure Matrices (SEM), which is used as  one of several resources in adjudicating claims. The SEM is a repository  of information on worksites, toxic substances, and associated illnesses.  The SEM has come under scrutiny by claimant advocates and others  concerned about its role in supporting claims adjudication. In addition, we  have previously reported on concerns about the scientific soundness of  the SEM’s data linking toxic substances with occupational illnesses. In  2010, we suggested Congress consider establishing an independent  board to review and report on the scientific soundness of the SEM.  Federal law established the Advisory Board on Toxic Substances and  Worker Health (Advisory Board) in 2014.

You asked us to review aspects of Part E claims for contracted Energy  workers and their survivors. In this review, we examined:  1.  How many compensation claims for illnesses resulting from exposure  to toxins did DOL reopen and what was their final outcome?  2.  To what extent has an advisory board on toxic substances and worker  health reviewed and advised DOL on the scientific soundness of  DOL’s database on toxins and their potential links to occupational  diseases, and how has DOL responded?

There is no generally accepted definition of the term “scientific  soundness.” For the purposes of this review, we define scientific  soundness in terms of the quality of the evidence on the health effects of  specified toxic substances, as determined by a systematic and  independent process to review and validate that evidence. We arrived at  this definition after consulting members of the Advisory Board and  officials of the National Academies of Sciences, Engineering, and  Medicine who reviewed the SEM. Additionally, we consulted with DOL  officials, who agreed that scientific soundness is related to the information  in the SEM on linkages between toxins and illnesses.

To answer our research questions, we reviewed DOL guidance and  procedures, including relevant bulletins and circulars, and the Federal  EEOICPA Procedure Manual. We also reviewed an internal DOL analysis  of reopened claims conducted in 2017; annual reports of the Office of the  Ombudsman; an independent review of the SEM conducted by the  Institute of Medicine in 2013; and the charter, minutes, and related  documents of the Advisory Board from April 2016 to January 2018. We  reviewed all recommendations of the Advisory Board and DOL’s  responses to those recommendations. We also reviewed federal laws,  regulations, and executive orders. In addition, we interviewed officials  from DOL and the Office of the Ombudsman, an office within DOL that  compiles and reports on claimants’ concerns; officials of the National  Academies of Sciences, Engineering, and Medicine; members of the  Advisory Board on Toxic Substances and Worker Health (Advisory  Board); and a claimant advocate.

To identify reopened Part E claims and their outcomes, we analyzed DOL  program data for calendar years 2012 through 2017. We selected data  beginning in 2012 to avoid any potential irregularities resulting from a  transition to a new data system in 2012. Because a claim may be  reopened at any time after it has been adjudicated with no limit to the  number of reopenings, we reviewed the most recently reopened claims  and their outcomes after reopening. To assess the outcomes of these  claims, using data that DOL provided, we examined both the initial  decision and subsequent final decision following reopening. We assessed  the reliability of the program data by (1) reviewing existing information  about the data and the system that produced them, and (2) interviewing  agency officials knowledgeable about the data. We determined the data  to be sufficiently reliable for the purposes of this report. See appendix I for  more information on our scope and methodology.

We conducted this performance audit from September 2017 to November  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.

EEOICPA, as amended, generally provides compensation to employees  of Energy under Part B, and under Part E, to its contractors, involved in  the production of U.S. nuclear weapons and who developed illnesses  related to their exposure to radiation and other toxins at Energy facilities.  During and shortly after World War II, the United States sponsored the  development, production, and testing of nuclear weapons. It used a  network of facilities which eventually expanded into a complex of as many  as 365 industrial sites and research laboratories throughout the country  that employed more than 600,000 workers. Some of the production sites  were owned by Energy or its predecessor agencies, and in many  instances contractors managed operations at the facilities. Workers used  manufacturing processes that involved handling dangerous materials and  were often provided inadequate protection from exposure, although  protective measures have increased over time. Because of national  security concerns, they also worked under great secrecy, were  unknowingly exposed to toxic materials, and often given minimal  information about the materials they handled and the potential health  consequences of exposure to them. In some cases, the extent of the  potential negative effects of the toxins may not have been fully  understood at the time of workers’ exposure.

EEOICPA, as amended, consists of two compensation programs, Part B  and Part E. The Part B program generally provides for $150,000 to  eligible current or former employees or their survivors, as well as  coverage of future medical expenses associated with certain radiogenic  cancer, chronic beryllium disease, and chronic silicosis. Part E provides  compensation to current or former contractors, subcontractors, or eligible  survivors of up to $250,000 for wage loss and impairment, as well as  coverage of medical expenses. Under certain circumstances, eligible  claimants may receive compensation under both Part B and Part E.

Claims Adjudication and Reopening Claims

Under Part E, a contracted Energy employee or survivor can file a  compensation claim, typically with a DOL district office (see fig. 1). Once  a claim is filed, a DOL claims examiner develops the claim and ultimately  recommends its approval or denial. To recommend an approval, the  claims examiner must determine that the claimant was a current or former  employee of an Energy contractor at a given Energy facility and that they  were exposed to a toxic substance at that facility. Additionally, the  examiner must find that it is at least as likely as not that the exposure was  a significant factor in aggravating, contributing to, or causing a covered  illness, and that the exposure was related to employment at an Energy  facility. One of the resources used by the claims examiner is the Site  Exposure Matrices (SEM), an online database of information on  worksites, toxic substances, and associated illnesses. If the claims  examiner determines that a claim meets all conditions, he or she  recommends that DOL’s Final Adjudication Branch approve the claim.  The Final Adjudication Branch then reviews the recommendation and  issues a final decision. If the claimant provides new evidence before a  final decision is reached, the Final Adjudication Branch may return the  claim to the district office for additional development or issue a reversal.  DOL provides some assistance to claimants as claims are adjudicated,  such as assistance that may be required to develop facts pertinent to the  claim, customer service activities, and information available in hard copy  and on DOL’s website. However, it is generally the claimant’s  responsibility to establish entitlement to compensation under the law.

If a claim is denied, claimants are informed of several options, one of  which is requesting that DOL reopen the claim. Claims can be reopened  any time after the Final Adjudication Branch has issued a final decision,  either as a result of a claimant request or agency action (see fig. 2).  There is no limit to the number of times a claimant may request a  reopening, though the claimant must either submit new evidence or  identify a change in a relevant program policy when submitting such a  request. Reasons for reopening can include an update to the SEM, new  medical evidence, or new evidence of covered employment, among  others. Moreover, a claimant may request reopening for each of multiple  illnesses or conditions. When a claimant requests a reopening, DOL will  review the request and either grant or deny the reopening, depending on  DOL’s assessment as to whether there is sufficient evidence to warrant  reopening. When a reopening request is granted, DOL vacates the  previous final decision and submits the claim for readjudication.

In addition, DOL may also reopen groups of related claims. When DOL  announces new evidence linking toxins to illnesses, it can also announce  plans to reopen groups of claims potentially affected by the new  evidence. In these instances, DOL announces the criteria for reopening,  which may involve specific substances or worksites, and provides  reopening instructions for claims examiners. For example, Circular 15-04,  issued in 2014 (now superseded) informed claims examiners that the  substance trichloroethylene had been linked to kidney cancer and that  previously denied Part E kidney cancer claims could be reopened. DOL  officials previously told us that such steps are limited to instances in  which a relatively large number of claims are potentially affected.

DOL claims examiners use the SEM to help determine workers’ eligibility  for Part E compensation. DOL created this web-based database which  organizes and communicates information on the toxic substances  workers were potentially exposed to at specific Energy worksites, certain  buildings at the worksites, and while doing specific jobs at the worksites.  As of May 2018, the SEM included information on 16,461 toxic  substances and 129 former and current sites. It also cross-references the  toxic substances with diseases for which there is an established link. In  general, the SEM contains only causal links that are based on  epidemiological studies, and for which there is medical and scientific  consensus. The SEM provides a basis for exposure information, but is not  the sole source of information considered by claims examiners during  adjudication (see fig. 3).

The SEM is publically available online and continually updated as new  exposure data are obtained. According to a 2016 DOL document, there  have been at least 656 revisions to the SEM since 2013. New links are  primarily drawn from a database of hazardous toxins and associated  diseases—known as Haz-Map—formerly maintained by the National  Library of Medicine. According to DOL officials, as new links are added to  Haz-Map, they are also added to the SEM.

In 2010, we reported that DOL’s efforts to update the SEM were not  subjected to independent outside review to provide assurance that the  SEM is comprehensive and scientifically sound. In 2013, the Institute of  Medicine evaluated the scientific rigor of the SEM in response to a  request from DOL. Its report noted that some examples of causal links  to diseases were missing from the SEM and questioned the SEM’s  exclusive dependence on Haz-Map as its source for disease and causal  information. The report also identified Haz-Map’s lack of peer review as a  key limitation. Specifically, the report noted that Haz-Map lacked  adequate oversight or content review by external, independent experts;  relied heavily on sources that were not peer-reviewed, such as textbooks;  and included references that were not easily accessible and were difficult  to check, making quality assurance and technical review difficult. In  addition, the report suggested that other sources be considered for  inclusion in the SEM.

Advisory Board on Toxic Substances and Worker Health

By law, the Advisory Board is tasked with providing specific categories of  technical advice to the Secretary of Labor regarding Part E of  EEOICPA. These categories are: (1) the SEM; (2) medical guidance for  claims examiners on weighing the medical evidence of claimants; (3)  evidentiary requirements for certain claims related to lung disease; and  (4) the work of certain experts, namely, industrial hygienists and  consulting physicians and their reports. The Advisory Board has  subcommittees aligned with these categories (see fig. 4).

The Advisory Board charter provides for 12 to15 members and for 2-year  terms for these members. Furthermore, applicable provisions of the  Federal Advisory Committee Act’s implementing regulations require that  Advisory Board membership be fairly balanced. Accordingly, its  members have included representatives of the medical, scientific, and  claimant communities. The Advisory Board is authorized until 2024.

The Office of the Ombudsman for EEOICPA is an independent office  within DOL. It was established by the National Defense Authorization Act  of 2005, to provide information to address the concerns of claimants and  potential claimants relating to EEOICPA, among other responsibilities.  The Office of the Ombudsman submits an annual report to Congress that  summarizes the number and types of complaints, grievances, and  requests for assistance that it has received during the year. The report  also includes an assessment of the most common difficulties encountered  by claimants and potential claimants each year. The Secretary of Labor is  required to provide a written response and must agree or disagree with  specific issues raised in the report. In addition, the Office of the  Ombudsman hosts and attends outreach events to assist claimants. The  Office of the Ombudsman may not make decisions on claims nor act as  an advocate for claimants.

DOL Reopened Thousands of Claims Since 2012 and Approved Almost 70 Percent, but Some Claimants Faced Evidentiary Challenges

DOL Reopened More Than 7,000 Claims by Contracted Employees for Exposure to Toxins at Energy Worksites and Approved Most

Based on the most recently reopened claims from calendar years 2012  through 2017, DOL reopened more than 7,000 claims filed by contracted  Energy employees. DOL subsequently approved compensation for 69  percent. The remaining claims were denied (13 percent), still awaiting a  final decision (2 percent), closed (2 percent), deferred (less than 1  percent) or had some other outcome (15 percent). (See fig. 5). Claims  with other outcomes refer to claims for which at least one claimed illness  was approved while the others were denied or deferred.

Among those more than 7,000 claims, DOL initiated most of the  reopenings (80 percent) itself, with fewer reopenings initiated by  claimants. Regardless of a claim’s previous status of approved or denied,  outcomes after reopening varied by who initiated the reopening. A higher  percentage of reopenings initiated by DOL were approved (73 percent, or  4,236 of 5,831 claims) than reopenings initiated by claimants (53 percent,  or 758 of 1,432 claims). (See table 1.)

Officials at DOL and the Office of the Ombudsman said that DOL-initiated  reopenings are more likely to be approved because, in deciding to reopen  claims, DOL had already determined there was sufficient evidence to  warrant reopening. In addition, DOL-initiated reopenings primarily involve  large groups of claims, according to DOL officials. They said that many  DOL-initiated reopenings are triggered by the establishment of cohorts of  claims for radiation-related cancer or by DOL bulletins or circulars about  new evidence linking toxins and specific illnesses at Energy worksites.  (For a list of DOL bulletins and circulars associated with reopenings, see  app. II.) In these situations, DOL officials said claims examiners  manually review all previously denied claims that could be affected.

Of the more than 7,000 reopened claims for contracted Energy  employees from 2012 through 2017, more than 6,000 had been  previously denied versus receiving another outcome. When reopened,  whether initiated by DOL or claimants, most (70 percent, or 4,307) were  approved (see table 2). In addition, as with all claims, a higher  percentage of previously denied claims were approved (75 percent) if  reopened at DOL’s initiative compared to those reopened at claimants’  initiative (52 percent).

Reasons Reopened Claims Were Denied Included Missing Linkage between Toxin and Illness and Insufficient Medical Evidence

DOL officials provided data showing that most of the claims reopened  from 2012 through 2017 that were subsequently denied compensation  had common reasons, including insufficient medical evidence, ineligible  survivors, or maximum benefits already met (see table 3).

Some Claimants Faced Challenges in Understanding What Evidence Was Required to Reopen Their Claim

According to Office of the Ombudsman officials, some claims may have  been denied as a result of claimants not understanding the evidence  required for a reopening. These officials also said that claimants  experience ongoing challenges at different stages of the adjudication  process, including reopening, with regard to evidence required to support  their claim. In the 2015 Annual Report to Congress, the Ombudsman  noted claimants’ concerns about the reopening process. In particular,  the Ombudsman found that DOL’s written communication with claimants  requesting additional evidence or informing them of the final decision did  not clearly explain what specific evidence was needed or why previously  submitted evidence was deemed insufficient. In its 2016 annual report,  while the Office of the Ombudsman acknowledged DOL’s efforts to  ensure that decisions on claims are adequately reasoned and  documented, and found that some recently issued decisions show  improvement, it also found some variation in decision quality among  claims examiners. Furthermore, consistent with its 2015 report, it also  found that some claimants encounter challenges during the reopening  process with written communication that is not clear on the evidence  needed to reopen a claim. Our prior work also found deficiencies in the  quality of a sample of DOL’s written communication with claimants and  recommended that all claimant correspondence for Recommended and  Final Decisions receive supervisory review. In that report, we noted that  DOL’s own monitoring also indicated that some of the letters were not  always clear about the evidence needed. Moreover, a recent review by  DOL’s Office of the Solicitor of 77 denied reopening requests found  shortcomings in the quality of some decision letters. These included the  lack of a clear explanation for the denial, discussion of medical evidence  submitted by the claimant, and discussion of why evidence submitted by  the claimant was considered insufficient to warrant a reopening. Office of  the Ombudsman officials told us that some claimants resubmit the same  evidence they provided previously. This is due, in part, to claims  examiners not acknowledging that they received and reviewed evidence  when it was initially submitted, or to decision letters not explaining why  the evidence submitted was not sufficient, according to Ombudsman  officials. Consequently, claimants do not know what specific additional  evidence may be needed and their claims may not be reopened and/or  approved for compensation, these officials said. Failure to establish  causation between exposure and illness and insufficient medical evidence  are the two most common reasons why claimant-initiated reopenings are  denied.

In its written response to the 2015 report by the Office of the  Ombudsman, DOL stated it was undertaking a review of its website and  printed material to improve communication with claimants. DOL also  stated that in 2015 it began providing training to claims examiners to  improve the quality of written letters to claimants, including better  explanation of what additional evidence would be needed to reopen a  claim. DOL stated that improved communication would address  claimants’ confusion and would allow staff to serve claimants on specific  issues.

As of July 2018, DOL officials said they have taken a number of steps to  assist claimants and improve communication with them. For example,  DOL conducts workshops for claimants’ Authorized Representatives  covering such topics as the evidence needed to support a claim and how  to request a reopening. DOL officials also said, in 2016, program  officials visited all district offices to provide training on topics such as  writing effective letters using reader-friendly language. Officials said that  they continually review printed material and are currently updating the  website to provide more concise information on the claims process,  including how to request reopening of a claim.

In addition, DOL officials stated that they recently hired a training analyst  to update claimant resources posted to the website and to develop  additional training for claims examiners. Officials said that the analyst will  also develop a methodology for assessing the effectiveness of the  training. Assessing the effectiveness of training represents an opportunity  for DOL to address claimants’ concerns about the clarity of written  correspondence they receive on claim evidence. According to Standards  for Internal Control in the Federal Government, management should  conduct ongoing monitoring and externally communicate the necessary  quality information to achieve the entity’s objectives. These standards  also require management to periodically evaluate its methods of  communication so that it has the appropriate tools to communicate quality  information. In addition, the EEOICPA Procedure Manual states that  claims examiners must ensure that written decisions are clear, concise,  and well-written with language that clearly communicates the necessary  information. An assessment of DOL’s training which considers claimant  concerns could help DOL better understand why some claimants remain  confused about the reopening process and do not submit evidence key to  supporting their claim. Until then, the agency will be unable to determine  whether its training has resulted in improving communication with  claimants and to target future training resources effectively.

DOL Has Not Fully Implemented Advisory Board Recommendation to Enhance Database Used to Support Claims

The Advisory Board in 2016 and 2018 recommended DOL incorporate  additional, peer-reviewed data sources on the links between toxic  substances and illnesses catalogued in the SEM, but while DOL  previously agreed that doing so would be useful, it has not yet added all  the sources recommended by the Advisory Board. According to Advisory  Board members, incorporating these additional sources would enhance  the SEM by making it more comprehensive and scientifically sound.

The Advisory Board’s work on the SEM began at its first meeting in April  2016 with the creation of a subcommittee on the SEM (see fig. 6). The  subcommittee reviewed the scientific soundness of the SEM and in  October 2016 the Advisory Board provided one of two related  recommendations to DOL that addressed the scientific soundness of the  SEM’s data on toxic substances and diseases.

At its October 2016 meeting, the Advisory Board recommended DOL  incorporate 13 additional information sources created by other agencies  or entities into the SEM. This recommendation was consistent with the  Institute of Medicine’s recommendation to DOL in its 2013 report on the  SEM. In September 2017, DOL responded to this recommendation,  noting that certain additional sources identified by the Institute of  Medicine might be useful. In its response, DOL asked the Advisory Board  to narrow its list of 13 databases to those that would be most relevant,  noting that DOL found that some of these sources were not relevant to  occupational exposure, were redundant, or contradicted other sources.  DOL also requested the Advisory Board’s advice on how the  recommended sources could be used in the SEM. In January 2018, the  Advisory Board made its second recommendation regarding the scientific  soundness of the SEM’s data on toxic substances and specific diseases  by identifying three priority information sources from the 13 originally  recommended in October 2016 (see table 4). According to DOL, the Haz- Map has included one of these three sources—the monographs on  human carcinogens of the International Agency for Research on  Cancer—since the Haz-Map was first published in 2002, and included in  the SEM since approximately 2006. According to DOL, the International  Agency for Research on Cancer is recognized as the world’s most  authoritative resource for information on human carcinogens and an  important source of information for populating health effect data in SEM,  given its assembled expertise and the scientific veracity of its  publications. Its incorporation in the SEM has prompted reopenings of  affected claims. DOL officials said Advisory Board members may have  been unaware of this earlier incorporation of data in the SEM. In its  response to DOL, however, the Advisory Board stated that it continued to  believe that incorporation of all of the information sources originally  recommended by the Institute of Medicine would be useful.

The Advisory Board’s recommendations on incorporating additional peer- reviewed information sources in the SEM were consistent with the earlier  report of the Institute of Medicine, which found that these additional data  sources generally follow a systematic methodology, reflect peer review,  provide more information on linkages between toxic substances and  specific diseases, and could enhance the scientific soundness of the  SEM.

The three information sources that the Advisory Board recommended for  inclusion in the SEM in January 2018 provide information on toxic  substances and their health effects, and all are peer-reviewed. The  Environmental Protection Agency’s Integrated Risk Information System  contains information on 511 chemicals and provides fundamental  scientific information used to develop human health risk assessments.  The National Toxicology Program’s Report on Carcinogens currently lists  248 substances, agents, and mixtures that are known or reasonably  anticipated to cause cancer in humans. The International Agency for  Research on Cancer, part of the World Health Organization, is considered  the authoritative source for information on cancer, according to officials of  the National Academies of Sciences, Engineering, and Medicine.

In August 2018, DOL responded to the Advisory Board’s recommendation  regarding these three potential additional data sources. DOL’s response  noted that it uses relevant data from the International Agency for  Research on Cancer in claims adjudication, including updates to these  data. Regarding the other two data sources, however, DOL declined the  recommendation. While noting that these two sources include voluminous  and complex data, DOL also noted that the Advisory Board did not offer  its own analyses of either the credibility or the scientific reliability of the  materials in these databases, and DOL did not think it appropriate to add  the databases’ information on health effects to the SEM in the absence of  any rigorous and comprehensive investigations by the Advisory Board.  DOL’s response also noted that it would consider additional input should  the Advisory Board be in a position to offer more specific guidance  regarding the content of data sources that would be applicable and  appropriate to the administration of the program.

Contracted Energy employees who carried out the nation’s nuclear  weapons production were often unaware of the extreme personal hazards  they faced while serving their nation and learned of the risk only when  they were later stricken by illness caused by exposure to toxins. It is  imperative their claims for compensation be given the attention and care  needed to fairly administer this compensation program. The most  scientifically up-to-date information should be used to determine the  health effects of various toxic substances, and claimants should be  assisted in their efforts to meet statutory requirements for claims. Despite  DOL efforts to improve the quality of written communication to claimants,  some claimants continue to be confused about the evidence needed to  successfully reopen and support their claim. DOL letters that clearly  communicate what evidence is needed to support a claim could provide  claimants with the opportunity to better understand the reopening process  while minimizing the frustration of having their claim repeatedly denied  and assuring a fair consideration of such claims.

We are making one recommendation:  The Secretary of Labor, in conducting any assessment of its staff training  designed to improve clarity of communication with claimants, should  ensure that the assessment considers claimants’ challenges with  understanding DOL’s written communications on the evidence needed to  successfully reopen or otherwise support a claim.

We provided a draft of this product to the Department of Labor (DOL) for  comment. In its comments, reproduced in appendix III, DOL neither  agreed nor disagreed with our recommendation to ensure that the  assessment of staff training considers claimants’ challenges regarding the  evidence needed to successfully reopen or otherwise support a claim.  However, DOL acknowledged that it plans to focus its staff training efforts  on a variety of needed training topics, including improving the quality of  written communications. DOL further noted that its recently hired training  analyst will be responsible for, among other things, designing assessment  measures to gauge the quality of training and the effect it has improving  the overall quality of claim outcomes. We continue to encourage DOL to  design its assessment so that it considers claimants’ challenges in  understanding the evidence needed.

DOL also provided technical comments, which we incorporated as  appropriate. In addition, we provided relevant report sections to the Office  of the Ombudsman, members of the Subcommittee on the Site Exposure  Matrices of the Advisory Board on Toxic Substances and Worker Health,  and officials of the National Academies of Sciences, Engineering, and  Medicine for their technical comments and incorporated them, as  appropriate.

As agreed with your office, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days from its  issue date. At that time, we will send copies of this report to the  appropriate congressional committees; the Secretary of Labor; and other  interested parties. In addition, the report will be available at no charge on  the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7215 or gurkinc@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made major contributions to this report  are listed in appendix IV.

Appendix I: Objectives, Scope, and Methodology

We examined (1) the number of compensation claims for illnesses  resulting from exposure to toxins that were reopened by the Department  of Labor (DOL) and their final outcome; (2) the extent to which an  advisory board on toxic substances and worker health reviewed and  advised DOL on the scientific soundness of DOL’s database on toxins  and their potential links to occupational diseases, and DOL’s response.

To address our objectives, we:  1.  Reviewed relevant federal laws, regulations and guidance;  2.  Requested summary data from 2012 to 2017 from DOL related to the  reopening process, including claims assessed for reopening, claims  actually reopened, and outcomes for reopened claims and, for claims  denied after being reopened, the reasons for denial;  3.  Reviewed DOL program documents;  4.  Reviewed recommendations of the Advisory Board on Toxic  Substances and Worker Health (Advisory Board) submitted to DOL  from October 2016 to January 2018, and DOL’s responses to those  recommendations, as well as Advisory Board minutes and other  documentation;  5.  Interviewed DOL officials; members of the Advisory Board on Toxic  Substances and Worker Health; officials of the National Academies of  Sciences, Engineering, and Medicine; and a representative of an  advocacy group.

Review of Federal Laws, Regulations, and Guidance  We reviewed relevant federal laws, including the Energy Employees  Occupational Illness Compensation Program Act of 2000 (EEOICPA),  the National Defense Authorization Act of 2015, National Defense  Authorization Act for Fiscal Year 2005, and the Federal Advisory  Committee Act, as well as relevant federal regulations. In addition, we  reviewed relevant guidance, including the Federal Energy Employees  Occupational Illness Compensation Program Act Procedure Manual, as  well as relevant Energy Employees Occupational Illness Compensation  Program Act Bulletins and Circulars.

Analysis of DOL Data on Reopened Claims and Subsequent  Decisions  To address our first objective, we obtained and analyzed data from DOL’s  Energy Compensation System from January 1, 2012 through December  31, 2017. We selected 2012 as the first year of our review period because  the program transitioned to a new data system that year, and 2017 as the  last year to obtain the most recent data available at the time of our  review. We obtained and analyzed data for the following types of claims:

Claims reviewed for reopening. We analyzed the data DOL  provided on claims that it reviewed for reopening, that is, claimant  requests for reopening (claimant-initiated reopenings), and claims  identified by DOL for potential reopening (DOL-initiated reopenings).  The total claims DOL reviewed for reopening was 10,652.

All claims actually reopened: We obtained the aggregate number of  all claims that were reopened. These claims totaled 8,234. We also  obtained data for each individual claim, including reopening request  date, reopening request type, reopening date, original final decision  type, and outcome type. The reopening request type indicates  whether the claim was claimant- or agency-initiated. The original final  decision type refers to the final decision when the claim was originally  adjudicated. The outcome type refers to the subsequent final decision  following reopening.

Most recently reopened claims: As we did for all reopened claims,  we obtained aggregate data on all the most recently reopened claims.  These claims totaled 7,263. By using the most recently reopened  claims, we were able to examine one claim for each claimant, to  provide a consistent unit of analysis, given that claimants can have  multiple claims at one time, and there is no limit on the number of  times they can request reopening of their claims. We also obtained  data on each individual claim that included the same categories as  those listed above for all reopened claims.

We assessed the reliability of the data obtained by (1) reviewing existing  information about the data and the system that produced them, and (2)  interviewing agency officials knowledgeable about the data. We  determined that the data were sufficiently reliable for purposes of  providing information on the number of claims for illnesses resulting from  exposure to toxins that DOL reopened since 2012 and the outcome.  However, there was one limitation to the data obtained: according to DOL  officials, the Energy Compensation System does not allow a particular  final decision to be linked to a particular reopened claim, given that claims  may be reopened multiple times and may be filed for multiple conditions.  As a result, DOL officials queried the system to match the final decision  issued most recently after the reopening as the basis of the provided  data. DOL officials explained that the data system’s codes used to record  final decisions do not reflect the full complexity of a case, and reflect the  fact that claims may be filed for multiple conditions. To illustrate this,  figure 7 depicts a hypothetical example of a claimant requesting  reopening of claims for three conditions (emphysema, hearing loss, and  bladder cancer) that had been denied previously. The code assigned to  the final decision, although appropriate, does not reflect the full  complexity of the claims’ history. In the example below, given that there  were three initial reopening requests for different conditions, a new  reopening request for one of these conditions (hearing loss), and two  subsequent final decisions, it is unclear from the coding in DOL’s system  which final decision corresponds to which reopening request.

We reviewed DOL summary tables on claims data to analyze the most  recently reopened claims from January 1, 2012 through December 31,  2017. To assess the outcomes of these claims, we examined both the  initial and subsequent final decisions. We first grouped DOL final  decisions into categories (see table 4). We decided to develop an “Other”  category so that claims with both approvals and denials would be  grouped together. Claimants can have multiple medical conditions and  when they receive a final decision, some medical conditions may be  approved while others are denied. Claims with such mixed outcomes are  coded in the Energy Compensation System as “Approved and Denied  Only” or “Approved, Denied and Deferred Only.” The code “Approved,  Denied and Deferred Only” refers to claims where a final decision has  been rendered on claims for some illnesses—approving at least one and  denying at least one—while a decision for at least one other claimed  illness is deferred for further development until it is ready for a final  decision. We then analyzed the initial and the subsequent final decisions.

To address our first objective, we reviewed certain program documents.  Specifically, we reviewed selected Accountability Reviews, which are  conducted by the Division of Energy Employees Occupational Illness  Compensation to monitor the quality of claims adjudication. According to  program officials, these reviews serve as a quality control tool and  regularly examine whether decisions on claims were supported as well as  issues such as payment accuracy. They may also occasionally include  other issues, including issues related to the reopening process. In  addition, we reviewed a review of reopening requests that were denied  conducted by the DOL Office of the Solicitor in 2017.

Additionally, we reviewed information related to reopened claims in the  annual reports of the Office of the Ombudsman for calendar years 2012  through 2015, and DOL’s responses to the reports for calendar years  2013 through 2015.

Review of Advisory Board Recommendations, DOL Responses, and  Other Documents  To address our second objective, we reviewed all recommendations that  the Advisory Board made to DOL about the Energy Employees  Occupational Illness Compensation Program Act of 2000, in order to  identify those recommendations related to the scientific soundness of the  Site Exposure Matrices (SEM), and DOL’s responses to these  recommendations. Specifically, we reviewed the eight recommendations  made by the Advisory Board in October 2016, and DOL’s response in  November 2017; the three recommendations made by the Advisory Board  in June 2017, and DOL’s response in March 2018; the seven overarching  recommendations made by the Advisory Board in April 2017, and DOL’s  response in September 2017; and the ten recommendations made by the  Advisory Board in January 2018, all of which referred back to previous  recommendations, in some cases revising the previous recommendation.  We also reviewed DOL’s responses to these recommendations in August  2018. In addition, we reviewed the Advisory Board’s charter and minutes  from selected meetings of the full Advisory Board and from the  Subcommittee on the Site Exposure Matrices.

In addition, in order to understand the Advisory Board’s recommendations  about the Site Exposure Matrices, we reviewed a report on the scientific  rigor of the SEM, Review of the Department of Labor’s Site Exposure  Matrix Database (Washington, D.C.: The National Academies Press,  2013). DOL asked the Institute of Medicine to review the SEM database  and its underlying source of toxic substance–occupational disease links.  To review the SEM, the Institute of Medicine formed an ad hoc committee  of experts in occupational medicine, toxicology, epidemiology, industrial  hygiene, public health, and biostatistics, who conducted an 18-month  study to review the scientific rigor of the SEM.

To address both objectives, we interviewed DOL officials and others with  relevant knowledge or experience of the Energy Employees Occupational  Illness Compensation Program Act of 2000. Specifically, we interviewed  officials of DOL’s Division of Energy Employees Occupational Illness  Compensation about topics including the reopening process, how data  about reopened claims are stored in the information system, reviews of  specific reopened claims, and DOL’s response to recommendations of  the Advisory Board. We also interviewed officials of DOL’s Office of the  Ombudsman for EEOICPA about topics such as claimants’ concerns  about the reopening process and about the SEM.

In addition, we interviewed officials of the National Academies of  Sciences, Engineering, and Medicine, who facilitated the work of the committee that produced the report, Review of the Department of Labor’s  Site Exposure Matrix. We asked the officials about topics such as the  process used to recruit experts for the review, the report’s methodology,  the report’s approach to scientific rigor, and the report’s  recommendations.

Additionally, we interviewed members of the Advisory Board on Toxic  Substances and Worker Health’s Subcommittee on the Site Exposure  Matrices, who represent the medical, scientific, and claimant  communities. We asked the Advisory Board members about topics such  as their review of the SEM and the priorities, if any, that they considered  in doing so; their approach to scientific rigor and scientific soundness; and  their recommendations to DOL. Finally, we interviewed a representative  of the Alliance of Nuclear Workers Advocacy Groups about topics that  included the challenges, if any, that claimants experience regarding  reopened claims and use of the SEM, and the Advisory Board’s  recommendations to DOL.

Appendix II: List of Department of Labor Bulletins and Circulars About Reopenings of Energy Employees Part E Claims

Energy Employees Occupational Illness Compensation Program Act  Bulletins Associated with Part E Reopenings  1.  Department of Labor, EEOICPA Bulletin 12-01, Chronic Lymphocytic  Leukemia (CLL) as Radiogenic Cancer under the Energy Employees  Occupational Illness Compensation Program Act (EEOICPA), March  7, 2012.  2.  Department of Labor, EEOICPA Bulletin 13-02, Systematic Review of  Denied Part E Cases, February 21, 2013.  3.  Department of Labor, EEOICPA Bulletin 16-01, Criteria for  Establishing Causation for Asthma Claims Under Part E of the Energy  Employees Occupational Illness Compensation Program Act  (EEOICPA), s, October 26, 2015.  4.  Department of Labor, EEOICPA Bulletin 16-02, Presumptions  Available for Accepting Chronic Obstructive Pulmonary Disease  (COPD) Under Part E of the Energy Employees Occupational Illness  Compensation Program Act, December 28, 2015.  5.  Department of Labor, EEOICPA Bulletin 16-03, Instructions for Use of  the Direct Disease Linked Work Processes (DDLWP) in the Site  Exposure Matrices (SEM) under Part E of the Energy Employees  Occupational Illness Compensation Program Act (EEOICPA), July 11,  2016.

Energy Employees Occupational Illness Compensation Program Act  Circulars Associated with Part E Reopenings  1.  Department of Labor, EEOICPA Circular 13-06, Review of Denied  Bladder Cancer Cases under Part E. (Superseded by Procedure  Manual Chapter 15), February 21, 2013.  2.  Department of Labor, EEOICPA Circular 13-12, Review of Denied  Ovarian Cancer Cases under Part E. (Superseded by Procedure  Manual Chapter 15), August 29, 2013.  3.  Department of Labor, EEOICPA Circular 15-04, Review of Cases  Involving Exposure to TCE and the Development of Kidney Cancer.  (Superseded by Procedure Manual Chapter 15), November 1, 2014.  4.  Department of Labor, EEOICPA Circular 15-05, Occupational  Exposure Guidance Relating to Asbestos. (Superseded by Procedure  Manual Chapter 15), December 17, 2014.  5.  Department of Labor, EEOICPA Circular 17-04, Rescind Post 1995  Toxic Exposure Guidance, February 2, 2017.  6.  Department of Labor, EEOICPA Circular 18-01, Idiopathic Disease  Diagnosis, December 6, 2017.

Appendix III: Comments from the Department of Labor

In addition to the contact named above, Meeta Engle (Assistant Director),  Chris Morehouse (Analyst-In-Charge), and LaToya King made key  contributions to this report. Also contributing to this report were Susan  Aschoff, James Bennett, Joseph Cook, Sheila R. McCoy, Jean McSween,  Alex Galuten, David Perkins, Tim Persons, Benjamin Sinoff, Almeta  Spencer, and Jerome Sandau.

Energy Employees Compensation: DOL Generally Followed Its  Procedures to Process Claims but Could Strengthen Some Internal  Controls. GAO-16-74. Washington, D.C.: March 10, 2016.

Energy Employees Compensation: Additional Independent Oversight and  Transparency Would Improve Program’s Credibility. GAO-10-302.  Washington, D.C.: March 22, 2010.

Energy Employees Compensation: Actions to Promote Contract  Oversight, Transparency of Labor’s Involvement, and Independence of  Advisory Board Could Strengthen Program. GAO-08-4. Washington,  D.C.: October 26, 2007.

Energy Employees Compensation: Adjustments Made to Contracted  Review Process, But Additional Oversight and Planning Would Aid the  Advisory Board in Meeting Its Statutory Responsibilities. GAO-06-177.  Washington, D.C.: February 10, 2006.

For decades, many government and contract workers building nuclear weapons were exposed to toxic substances. Since 2004, a Department of Labor program has provided $4.4 billion in compensation to those claiming exposure-related illnesses.

Earlier we found Labor's explanations of claim denials and the evidence needed to support a claim could be unclear. This could make it harder to refile denied claims.

This report found Labor ultimately approved many denied claims. From 2012 through 2017, it reopened 7,000 claims and approved 69% of them.

We recommended better training for claim reviewers on communicating what is needed to reopen a claim.