Detailed Information on the
Radiation and Exposure Screening and Education Program Assessment

Partnering with the Department of Justice to collect data in support of newly developed long-term performance measures

Develop RESEP clinic depression screening guidelines and referral protocol in accordance with USPTFSG.

Increase RESEP National Outreach to spread the word about RESEP (will include partnering with other Federal agencies).

Ensuring grantees comply with Agency for Healthcare Research and Quality's Preventative Task Force Screening Guidelines (USPTFSG)

Measure: Percent of RECA successful claimants screened at RESEP centers.

Explanation:The Radiation and Exposure Screening and Education Program (RESEP) was created to help individuals exposed to uranium or nuclear testing identify and receive compensation under the Department of Justice's Radiation Exposure and Compensation Act (RECA) program for illnesses that may have resulted from these activities. This long term measure reflects RESEP's primary purpose to screen and educate those that might be eligible for compensation under the RECA. As not all RECA claimants are screened at RESEP centers, this measure examines the overall role of the program plays in helping people receive RECA benefits. The measure will be determined by comparing the number of successful RECA claimants screened through RESEP centers (i.e. the numerator) with the total number of successful RECA claimants (i.e. the denominator). This is a developmental measure since there is not sufficient data currently to set a baseline.

Measure: Percent of persons screened at RESEP clinics who file RECA claims that receive RECA benefits.

Explanation:This long-term measure reflects the program's efforts to accurately screen and refer further individuals potentially eligible for RECA claims. Findings from RESEP's screenings must be confirmed outside the screening program through definitive diagnostic tests in order for an individual to receive benefits. The measure will be determined by comparing the number of successful RECA claimants screened through RESEP centers as reported to the Department of Justice (i.e. the numerator) with the total number of RECA claimants screened at RESEP centers as reported to the Department of Justice(i.e. the denominator). This is a developmental measure since there is not sufficient data currently to set a baseline.

Measure: Total number of individuals screened per year.

Explanation:An increase in the total number of individuals screened at RESEP centers should increase the number of RECA successful claimants, thus, supporting RESEP's long-term measure. This measure defines screening as including: 1) occupational history; 2) medical history; 3) physical examination; 4) diagnostic testing (when appropriate); and 5) access to a range of comprehensive services including outreach, education, case management, referrals for treatment, and assistance in applying for RECA compensation. Targets reflect program estimates that the number of individuals screened will slow down over time due to a finite aging population. It is likely that many individuals most interested in/aware of program services (particularly uranium mine workers) will have been served during the early years of the program. In addition, the program will potentially reach many of these eligible individuals in the service area due to the aging of this population. Consequently, it will be more challenging for the program to expand the number of persons served in future years. However, there is some program growth potential among downwinders and persons who worked above ground at mining sites who are also eligible for RESEP services. The 2009 estimates reflect the recent restructuring of the Arizona clinic program and the potential for funding applicants in more eligible states could add, in the near future, to number of persons screened.

Measure: Total number of telephone inquiries to RESEP clinics based on expanded nationwide outreach efforts.

Explanation:The second measure expands the programs' local outreach activities to a nationwide approach attempting identify individuals potentially exposed, who no longer reside in the local area. Though some RESEP grantees currently collect information from each inquiry to determine where the person heard about the RESEP program, there is no program-wide data collection system yet. Thus, this annual measure is developmental as we seek to implement a streamline process of data collection.

Measure: Average cost of the program per individual screened.

Explanation:The efficiency measure looks at the total costs of the program and the program's ultimate result of getting individuals screened. The average cost per individual screened is based on the fiscal year dollars spent to pay for the screenings not the year that services were received. The costs include all education and outreach efforts as well as the costs of the screening exams.

Is the program purpose clear?

Explanation: The purpose of the Radiation Exposure Screening and Education Program (RESEP) is to help individuals involved with the mining, transport, and processing of uranium and the testing of nuclear weapons for the Nation's weapon arsenal identify, prevent, and receive compensation for illnesses that may have resulted from those activities. This is accomplished by providing competitive grants to States, local governments, and other eligible entities to establish and support programs that: screen individuals who may have been exposed to radiation through the development of nuclear weapons or the uranium mining industry for cancer and other related diseases. This screening includes: 1) occupational history; 2) medical history; 3) physical examination; 4) diagnostic testing (when appropriate); and 5) access to a range of comprehensive services including outreach, education, case management, referrals for treatment, and assistance in applying for Radiation Exposure and Compensation Act (RECA). RESEP is administered by the Health Resources and Services Administration (HRSA) in the Department of Health and Human Services (HHS).

Evidence: Section 417C of the Public Health Service Act authorizes grants for education, prevention, and early detection of radiogenic cancers and diseases. RESEP Guidance includes program requirements and describes who is eligible to provide services and who is eligible to receive services. Entities that may apply for grants must be located in one of the 12 states that are believed to have been most affected by nuclear weapons development activities. Entities that may receive grants include: health centers, State and local governments, non-profit organizations, National Cancer Institute-designated cancer center, and the Department of Veterans Affairs. Persons eligible to receive screening and referral services include persons who participated in nuclear arms tests, persons who resided in areas between 1945 and 1962 that are believed to have been adversely impacted by aboveground nuclear arms tests ("downwinders"), and individuals employed in the uranium mining and milling or the ore transportation industry between 1942 and 1971. RESEP screens for 20 malignant conditions in downwinders and onsite participants, seven malignant and nonmalignant conditions in uranium millers and ore transporters, and six additional conditions in miners

Does the program address a specific and existing problem, interest, or need?

Explanation: The program addresses problems that exist in certain populations. Between 1945 and 1962, the United States conducted a series of aboveground nuclear arms tests in which people were exposed to radiation. Individuals employed in the uranium mining, milling, and ore transportation industry between 1942 and 1971 were also at risk of exposure to radiation. Congress found that activities related to the development of nuclear weapons generated excess cancers and respiratory diseases and that restitution was appropriate. In response, Congress established RECA to compensate individuals diagnosed with specific cancers and chronic diseases that may have resulted from radiation exposure. Studies have also shown that uranium miners are at increased risk for developing certain types of cancers. Studies have found that millers and onsite participants may be at greater risk of developing certain radiogenic diseases.

Evidence: In Section 2(a) of the Radiation Exposure Compensation Act (P.L. 101-426), Congress made a series of finding which concluded that the development of the Nation's nuclear arsenal generated excess cancers among uranium miners and millers, onsite nuclear test participants, and downwinders. In "Assessment of the Scientific Information for the Radiation Exposure Screening and Education Program," the National Research Council reviewed epidemiologic studies on the affected populations and found evidence that radiation exposure significantly increased lung cancer risk among uranium miners. There is also evidence that radiation exposure increases cancer risk among uranium millers. There have been no definitive epidemiological studies of the radiation risk to downwinders.

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: RESEP is the only Federal program designed for the early detection, prevention, and education of radiogenic diseases. Other cancer screening programs at the state, local and/or private level exist, but RESEP is unique in its implementation of outreach, early detection of disease and education regarding radiogenic diseases for a specific population (i.e. those individuals eligible for RECA).

Evidence: Section 417C of the Public Health Service Act authorizes grants for education, prevention, and early detection of radiogenic cancers and diseases. Medicare and some private insurance programs pay for diagnostic testing procedures when the results of a history and physical examination or screening test suggest the possibility of disease. These diagnostic testing procedures can include, but are not limited to chest x-rays, pulmonary function testing, arterial blood gases, laboratory studies, imaging studies, endoscopies, and biopsies. RESEP is the only Federally supported screening program for individuals exposed to radiation or as a result of nuclear testing and employment in the uranium industry.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: An evaluation conducted by the National Research Council recommended an alternative program design as a more effective method of delivering services. RESEP currently distribute funds through a competitive grant process. The evaluation found program grantees provide "different (or different levels of) services to eligible populations" and "they risk inadvertently discriminating against some populations and for others." The evaluation recommended the program use contracts instead of competitive grants as "the most efficient and effective mechanism of administration. The use of contracts rather than grants for program implementation would require a legislative change. In addition, the same evaluation found little medical benefit from screening for many of the diseases identified for RESEP screening. Low disease prevalence, lack of effective therapeutic treatments, and/or the uncertainty associated with available tests (high likelihood of a false positive) may result in harm that outweighs benefits. Such harm can include physiological harm from stress, physical harm from further testing and unnecessary treatment, and societal harm from discrimination. The report recommends that RESEP provide medical screening in asymptomatic individuals only when there is robust scientific evidence that such screening improves health outcomes and that its benefits outweigh risks. In addition, it recommended that individuals screened for compensation be made aware of the tradeoffs and benefits of screening and the risks it poses, especially as "few health benefits are likely to accrue (but harms may well) and the likelihood of successful claims is low."

Evidence: In the "Assessment of the Scientific Information for the Radiation Exposure Screening and Education Program," the National Research Council offers a number of recommendations to improve program design, including: using contracts to standardize protocols; following medical screening guidelines for the general population developed by the U.S. Preventative Services Task Force (with additional screening of uranium miners, millers, and ore transporters for diseases known to be common in mining populations); and using proposed tests only where there is credible scientific evidence that they supply reliable information about the presence or absence of specific RECA-compensable diseases.

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: Resources are targeted so that they only reach intended beneficiaries; however, there is no evidence that the program is effectively targeted to reach the maximum number of beneficiaries or the beneficiaries who are at greatest risk. Some program elements target its services to the affected population. Only persons directly affected in the specific time periods are eligible for program services. Grantees must conduct outreach to attract these persons. Grants are given to health care organizations located in the 12 states where these activities occurred. There is no estimate of how many people were potentially affected by these activities and where they currently live. Therefore, it is impossible to determine if program resources are effectively targeted. People who have moved out of areas that receive grant funds are unlikely to receive services, but there is no information on what portion of eligible people have moved out of the targeted area. Funding is not targeted to screen those groups who are at most risk to develop radiogenic diseases. For example, uranium miners have been proven to be at high risk for developing cancer. There is less evidence concerning downwinders.

Evidence: In Section 2(a) of the Radiation Exposure Compensation Act (P.L. 101-426), Congress made a series of finding that the development of the Nation's nuclear arsenal generated excess cancers among uranium miners and millers, onsite nuclear test participants, and downwinders. In "Assessment of the Scientific Information for the Radiation Exposure Screening and Education Program," the National Research Council reviewed epidemiologic studies on the affected populations and found evidence that radiation exposure significantly increased lung cancer risk among uranium miners. While there was some evidence that radiation exposure increased risks for radiogenic diseases among the other populations, it was not as conclusive.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: The program has two long-term measures that reflect the program's purpose to help eligible individuals identify and receive compensation for illnesses that may have resulted from activities associated with the development of nuclear weapons. The first measures the overall role of the program in helping people receive RECA benefits. The second measures the program's efforts to accurately screen and refer further individuals potentially eligible for RECA claims. Findings from RESEP's screenings must be confirmed outside the screening program through definitive diagnostic tests in order for an individual to receive benefits.

Evidence: RESEP's two long-term performance measures are 1) Percentage of successful RECA claimants who were screened at RESEP centers; and 2) Percentage of patients screened at RESEP clinics who actually receive RECA claims

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The program has not yet developed targets or timeframes for its long-term measures

Evidence: RESEP is working with the Department of Justice to obtain the necessary data to generate a baseline by 2008 and a long term target for 2013.

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: The program has two annual output measures that serve to achieve its long-term goal of helping eligible individuals identify and receive compensation for illnesses that may have resulted from activities associated with the development of nuclear weapons. The first measures the number of individuals screened per year by RESEP centers. The second measure expands the programs' local outreach activities to a nationwide approach attempting identify individuals potentially exposed, who no longer reside in the local area.

Evidence: The program's annual measures are: (1) Total number of individuals screened per year. (2) Total number of telephone inquiries to RESEP clinics based on expanded nationwide outreach efforts.

Does the program have baselines and ambitious targets for its annual measures?

Explanation: The program has targets and baselines for the total screenings annual measure. The program does not yet have targets and baselines for the expanded outreach measure. The targets are ambitious given the population that it serves.

Evidence: The program's goal is to increase the total number of individuals screened by 10 percent in 2005 and by 5 percent in 2006 and thereafter. The program has existed for only three years and it estimates that the rate of increase of individuals screened will slow down over time. It is likely that those individuals most interested in/aware of program services will have been served during the initial start up of the program. Consequently, it will be more difficult for the program to expand services in future years. In addition, the program will potentially reach all the eligible individuals in the service area due to a finite aging population. A baseline for the expanded outreach activities is anticipated in 2009.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: Grantees measure and report on performance as it relates to accomplishing the program's annual goals in the Office of Performance Review (OPR) process. In the OPR process, grantees set quarterly goals related to the program's annual goals of total number of screenings and number of people contacted through outreach activities. Grantees also track progress towards achieving these goals. OPR uses this data to help grantees improve performance. As the OPR process happens only every three years, the program could improve on this process by having grantees include performance goals in their quarterly reports.

Evidence: Performance Reports issued by OPR includes quarterly performance goals and actual performance related to achieving program goals.

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: In May 2005, the National Research Council (NRC) published an evaluation of RESEP entitled "Assessment of the Scientific Information for the Radiation Exposure Screening and Education Program," in which it analyzed the current state of scientific evidence associating radiation exposure with cancers and other health affects. The evaluation provided recommendations on improving accessibility and quality of medical screening, education, and referral services. It also reported on the most recent scientific information related to radiation exposure and associated cancers and other diseases, with recommendations for improving services.

Evidence: NRC findings and recommendations are discussed as the Executive Summary of the report. A copy of the full report can be found on the National Academies website: www.national-academies.org

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: Budgets are not explicitly tied to accomplishments of annual and long-term goals. The relationship between annual and long-term targets and budget resources is not clear.

Evidence: The budget justification for RESEP is included in the Health Resources Administration Fiscal Year 2007 Justification of Estimates for Appropriation Committees.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: The budget justification for RESEP is included in the Health Resources Administration Fiscal Year 2007 Justification of Estimates for Appropriation Committees.

Evidence: The program developed new outcome measures in 2006.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: Grantees regularly submit performance plans and reports to RESEP. Data collected in these reports are used to set baselines for some of the program's performance measures and to identify technical assistance needs of grantees. A program evaluation found that the way that different grantees report data varies. HRSA also monitors grantees through on-site visits. These visits result in recommendations on how grantees could improve performance.

Evidence: Grantees submit competing applications every 3 years and non-competing applications annually. These applications describe planned activities and proposed budgets. Grantees also submit standardized annual and quarterly data on key program outputs, such as the number of outreach/education encounters and the number of screenings, including diagnostic mix, referrals, and follow-up. These quarterly and annual data reporting instruments are located on pages 39-43 of the RESEP Program Guidance (HRSA-05-105). In its review of this data, the National Research Council found variation among grantees in how they counted people reached through education and clinical outcomes, such as numbers of persons with abnormal tests or possible diagnosis. Grantee performance is monitored through sites visits by project officers within the first year of the initial award of grant funds. In addition, the Office of Performance Review conducts thorough reviews every 3 years and issues a Performance Report. Grantees follow-up these reviews by issuing an Action Plan, which include a list of specific tasks that they intend to perform to improve performance and management.

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: RESEP program managers' contracts currently lack quantifiable performance standards. Grantees identify key managers and the performance activities which they are responsible for in program applications. Terms and conditions of RESEP awards are include in the official notification of award. If grantees fail to meet these terms and conditions, continued funding could be affected. A recent Office of Inspector General (OIG) report found that HRSA had trouble notifying grantees about corrective actions.

Evidence: The program is in the process of updating RESEP program managers' performance contracts. Grantee applications include a list of performance activities and the persons responsible for accomplishing those objectives. HRSA's official notification of award is provided to the applicant in a Notice of Grant Award (NGA). The NGA establishes the terms and conditions of the award. Special conditions and/or management assessment items are placed on an award if budget or management issues are identified. If issues are not addressed, continued funding could be affected. If a grantee fails to meet financial and/or programmatic reporting requirements they are placed on a corrective action plan to address the problem(s). The corrective action plan is closely monitored by the project officer. If issues remain unresolved, drawdown restriction could be placed on the grantee's grant funds. Finally, a removal or reduction for continuation of funding could occur. However, a May 2006 OIG Report, "Use of the Departmental Alert List by HRSA," found that some grantees who received special condition awards did not receive letters indicating the corrective actions required, the time period for correction, and a description of the consequence of not completing the action required. In addition, in some cases where grantees had payment-related special award conditions, the Payment Management System was not notified.

Are funds (Federal and partners') obligated in a timely manner, spent for the intended purpose and accurately reported?

Explanation: Funds are obligated on an annual basis, usually within 1 week after the Notice of Grant Award has been issued. RESEP program officers monitor grants through budgets included in program applications and financial reports. In the last 3 1/2 years there have been no grantees out of compliance with regard to appropriately obligating and expending grant funds. In FY 2004, two grantees reported unobligated balances, amounting to approximately $40,000 each. All grantees undergo annual independent financial audits. In 2005, one grantee received a qualified opinion.

Evidence: The Notice of Grant Award (NGA) is usually issued on September 1, the first day of the budget period. All grantees are required to submit a proposed budget with their grant applications. Any change in budgets must be approved by the Division of Grants Management. Project officers monitor grantee expenditures through periodic progress reports. Each year grantees submit Financial Status Reports (FSR), a cash transaction report on the drawdown of funds. Grantees are required to submit audits under the Single Audit Act to ensure appropriate use of funds. Program awards are reported in FAADS

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: RESEP has developed an efficiency measure that examines the average cost of the program per individual screened. In addition, the program is increasing efficiency through the establishment of a RESEP IT web based data collection and reporting report tool on the Bureau of Primary Health Care's (BPHC) Health Disparities website. The Health Disparities Collaboratives includes cancer screening pilot that is focusing on identifying effective processes of care that would lead to improvements in improvements in breast, colon and cervical cancer screening and follow up. RESEP has taken steps towards a pilot to evaluate/test the data fields, common factors, and issues related to data reporting that might be incorporated in the Health Disparities reporting instrument.

Evidence: RESEP's efficiency measure is: Average cost of the program per individual screened. Additional information on the BPHC Health Disparities website is available at www.healthdisparities.net.

Does the program collaborate and coordinate effectively with related programs?

Explanation: The program could improve coordination with the Department of Justice. The program has collaborated informally with the Department of Justice in the past. The program has begun coordination with the Department of Justice RECA program to seek information on RESEP grantees. It is important that such coordination occur so that the program can gain an understanding of the outcomes of RESEP. RESEP has initiated contact with the Department of Labor to increase the understanding about the Energy Employees Occupational Illness Compensation Program Act (EEOICPA) and to find opportunities for sharing and increased coordination between programs.

Evidence: RESEP has recently reached out to the Department of Justice, which administers RECA, to obtain data on what portion of RESEP screenings lead to RECA compensation. In June 2005, Department of Labor staff made a presentation during the RESEP session of HRSA's All Grantee Meeting. The presentation is available in hard copy or via the internet at: http://www.psava.com/phc2005/presentations.asp.

Does the program use strong financial management practices?

Explanation: In 2005, HHS received a material control weakness for its financial systems and processes. HRSA contributes to the material internal control weakness identified in the 2005 HHS audit. HHS is in the process of resolving these weaknesses by replacing existing accounting systems within HHS with the Unified Financial Management System (UFMS). UFMS is scheduled to be operational for HRSA in October 2006.

Evidence: Since 2003, HRSA has been not been included in a consolidated HHS audit. In a 2005 audit of HHS, Ernest and Young found a material weakness in HHS financial systems and processes. In particular, the audit found: Documentation regarding significant accounting events, recording of non-routine transactions and post-closing adjustments, as well as correction and other adjustments made in connection with data conversion issues must be strengthened. Processes to prepare financial statements need improvement. Financial systems are not FFMIA compliant. Weaknesses were identified in Department/Operating Division Periodic Analysis, Oversight and Reconciliations In addition, the audit found PSC's DFP CORE accounting system, which supports the activities of HRSA, did not facilitate the preparation of timely financial statements and did not have an efficient mechanism in place to compile accounting statements.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: The program is taking steps to address its identified management deficiencies including an increased effort to collaborate with the Department of Justice and a commitment to incorporating goals of the RESEP program into the management performance contracts. HRSA is in the process of switching over to the UFMS to improve its financial management. The UFMS will improve funds control and monitoring and provide real-time data.

Evidence: Once the organizational change in management of the RESEP program has been finalized, the performance management contract for senior HRSA managers will reflect the goals of the RESEP program. A discussion has taken place between HRSA and DOJ regarding the potential development of an inter-agency agreement to assist in fulfillment of the data requirements for the RESEP program's long term measure using the DOJ data. HHS documents indicate that HRSA will adopt the UFMS system in 2006.

Are grants awarded based on a clear competitive process that includes a qualified assessment of merit?

Explanation: One-hundred percent of the grants awarded by RESEP are reviewed, ranked, and awarded according to a competitive process. There are no earmarks, and all awards are subject to peer review. At the end of the project period, RESEP grants are made available through a competitive process that allows other applicants to apply for the program. This opportunity is announced in the HRSA Preview. After grants are awarded, they are posted to Grants.gov.

Evidence: The Review Criteria and Selection Process for RESEP applicants are cited on pages 21-28 of the RESEP Program Guidance (HRSA-05-105).

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: The program lacks a reporting system to document grantees' use of funds by activity. While grantees submit an initial budget with their three-year applications, breaking down spending by activity, the program does not seek follow-up reports to verify if actual expenditures were used for their initial designated purpose. In addition, the HHS OIG found that HRSA did not consistently adhere to policies intended to safeguard agency funds by using the Alert List, a mechanism intended to help increase monitoring and oversight of grantees considered a financial risk.

Evidence: Aside from program applications, the main source of information on use of program funds comes from Financial Status Reports (FSR) and audits conducted under the Single Audit Act. These reports track grantee spending on a broad level to ensure they are in compliance with Federal law. These documents do not enable the program to track grantee spending by activity. A May 2006 OIG Report, "Use of the Departmental Alert List by HRSA," found that HRSA did not consistently adhere to policies governing the use of the HHS Alert List. The report found that HRSA did not consistently place grantees on the Alert List, nor did it consistently check the list or document monitoring of Alert List Grantees.

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The program makes performance data available to the general public on the numbers of screening, outreach, and education activities.

Evidence: The Radiation Exposure Compensation Act (RECA) amendments of 2000 (P.L. 106-245) requires an Annual Report to Congress that summarizes program expenditures. This report is available at: http://bphc.hrsa.gov/resep/resepreporttocongress2003.htm

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: The program does not currently collect data that can demonstrate progress on its long-term goals.

Evidence: The program plans to begin collecting data in September 2008. At that time it will have a baseline and will be able to project a target for both measures for 2013.

Does the program (including program partners) achieve its annual performance goals?

Explanation: The program has met its annual goal to increase the number of individuals screened. Baseline information for the expanded outreach measure is not currently available.

Evidence: In 2003, the number of individuals screened increased by 47 percent. In 2004, the number of individuals screened increased by 28 percent.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: The program has demonstrated improved efficiency in the average cost the RESEP program per individual screened since fiscal year 2002. However, the program has also achieved limited efficiencies of scale to date.

Evidence: The average cost of the RESEP program per individual screened fell from $3,030 in 2002 to $1,062 in 2004.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: There are no other programs with a similar purpose or goals.

Evidence: Question 1.3 explains how the program is not duplicative of any other government or private effort.

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: In the "Assessment of the Scientific Information for the Radiation Exposure Screening and Education Program," the National Research Council found that the program design could be improved to be more effective and to better achieve results. The evaluation a offers a number of recommendations to improve program design, including: using contracts to standardize protocols; following medical screening guidelines for the general population developed by the U.S. Preventative Services Task Force (with additional screening of uranium miners, millers, and ore transporters for diseases known to be common in mining populations); and using proposed tests only where there is credible scientific evidence that they supply reliable information about the presence or absence of specific RECA-compensable diseases.

Evidence: The Executive Summary of the NAS/NRC findings and recommendations provides details regarding necessary improvements in the quality of screening and education for the program.