Health and Human Services: Status of Achieving Key Outcomes and  
Addressing Major Management Challenges (15-JUN-01, GAO-01-748).  
								 
This report reviews the Department of Health and Human Service's 
(HHS) fiscal year 2000 performance report and fiscal year 2002	 
performance plan required by the Government Performance and	 
Results Act of 1993 to assess HHS' progress in achieving selected
key outcomes that are important to its mission. It is difficult  
to fully assess the HHS' progress in fiscal year 2000 toward	 
achieving the outcomes GAO reviewed because lags in reporting	 
performance data are common for many of its components such as	 
the Administration for Children and Families (ACF), Centers for  
Disease Control and Prevention (CDC), the Substance Abuse and	 
Mental Health Services Administration, and the Food and Drug	 
Administration. In some cases, the delays are associated with the
need to obtain performance data from states and local		 
organizations. Some HHS components are working to improve the	 
timeliness of data submitted by others and, in some instances,	 
have reported trend data to show that progress is being made. For
example, both ACF and CDC supplied fiscal year 1999 performance  
data in their current performance reports--data that were not	 
available until this year. It is likely that ACF's and CDC's	 
fiscal year 2001 performance reports will include fiscal year	 
2000 performance data that were not available this year. While it
may not always be realistic to expect the availability of	 
complete data at the same time annual performance reports and	 
plans are issued, trends will become apparent as the number of	 
performance reports grows with each passing year.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-01-748 					        
    ACCNO:   A01229						        
  TITLE:     Health and Human Services: Status of Achieving Key       
             Outcomes and Addressing Major Management Challenges              
     DATE:   06/15/2001 
  SUBJECT:   Health care programs				 
	     Performance measures				 
	     Program evaluation 				 
	     Reporting requirements				 
	     Strategic planning 				 
	     Data collection					 
	     Personnel management				 
	     Information resources management			 
	     FDA Human Drug Program				 
	     FDA Medical Device Program 			 
	     HHS At-Risk Child Care Program			 
	     HHS Child Care and Development Fund		 
	     HHS Child Support Enforcement Program		 
	     HHS Nursing Home Oversight Improvement		 
	     Program						 
								 
	     HHS Refugee Cash Assistance Program		 
	     HHS Refugee Resettlement Program			 
	     HHS Temporary Assistance for Needy 		 
	     Families Program					 
								 
	     Medicaid Program					 
	     Medicare Program					 
	     SAMHSA Substance Abuse Prevention and		 
	     Treatment Block Grant Program			 
								 
	     State Children's Health Insurance			 
	     Program						 
								 
	     GPRA						 
	     Government Performance and Results Act		 

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GAO-01-748
     
Report to the Ranking Minority Member, Committee on Governmental Affairs, U.
S. Senate

United States General Accounting Office

GAO

June 2001 HEALTH AND HUMAN SERVICES

Status of Achieving Key Outcomes and Addressing Major Management Challenges

GAO- 01- 748

Page i GAO- 01- 748 HHS' Status of Achieving Key Outcomes Letter 1

Appendix I Observations on HHS? Efforts to Address Its Major Management
Challenges 33

Appendix II Comments From the Department of Health and Human Services 39

Tables

Table 1: Major Management Challenges 33

Abbreviations

ACF Administration for Children and Families AoA Administration on Aging CDC
Centers for Disease Control and Prevention FDA Food and Drug Administration
FFMIA Federal Financial Management Improvement Act GPRA Government
Performance and Results Act of 1993 HCFA Health Care Financing
Administration HHS Department of Health and Human Services HRSA Health
Resources and Services Administration IHS Indian Health Service NIH National
Institutes of Health OCR Office for Civil Rights OIG Office of Inspector
General OSCAR On- Line Survey, Certification, and Reporting PPS prospective
payment system SAMHSA Substance Abuse and Mental Health Services

Administration TANF Temporary Assistance for Needy Families Contents
Contents

Page 1 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

June 15, 2001 The Honorable Fred Thompson Ranking Minority Member Committee
on Governmental Affairs United States Senate

Dear Senator Thompson: To assess the progress of the Department of Health
and Human Services (HHS) in achieving selected key outcomes that you
identified as important mission areas, we reviewed HHS? fiscal year 2000
performance reports and fiscal year 2002 performance plans required by the
Government Performance and Results Act of 1993 (GPRA). 1 For HHS, these
documents consist of an overall departmental summary and a combined report
and plan from each of 17 operating components and staff offices. 2 Our
review generally covered the same outcomes we addressed in our June 2000
review of HHS? fiscal year 1999 performance reports and fiscal year 2001
performance plans to provide a baseline by which to measure HHS? performance
from year to year. 3 These selected key outcomes are

 less fraud, waste, and error in Medicare and Medicaid;  beneficiaries
receive high- quality nursing home services;  poor and disadvantaged
families and individuals become self- sufficient;  improved prevention of
infectious diseases, including vaccine- preventable

diseases;  reduced use of illegal drugs; and  public has prompt access to
safe and effective medical drugs and devices.

1 This report is one of a series of reports on the 24 Chief Financial
Officers Act agencies? fiscal year 2000 performance reports and fiscal year
2002 performance plans. 2 Our review focused on the reports and plans of the
following HHS components: Administration on Aging, Administration for
Children and Families, Centers for Disease Control and Prevention, Food and
Drug Administration, Health Care Financing Administration, Health Resources
and Services Administration, Indian Health Service, National Institutes of
Health, Office for Civil Rights, and Substance Abuse and Mental Health
Services Administration.

3 Observations on the Department of Health and Human Services? Fiscal Year
1999 Performance Report and Fiscal Year 2001 Performance Plan (GAO/ HEHS-
00- 127R, June 30, 2000).

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

As agreed, using the selected key outcomes for HHS as a framework, we (1)
assessed the progress HHS has made in achieving these outcomes and the
strategies it has in place to achieve them and (2) compared HHS? fiscal year
2000 performance reports and fiscal year 2002 performance plans with its
prior- year performance reports and plans for these outcomes. We also agreed
to analyze how HHS addressed major management challenges that we and HHS?
Office of Inspector General (OIG) identified, including the governmentwide
high- risk areas of strategic human capital management and information
security. (App. I provides detailed information on how HHS addressed these
challenges. App. II contains HHS? comments on a draft of this report.)

Overall, the reports and plans of HHS components indicated that they had
made mixed progress in achieving their key outcomes. In general, the
components? strategies for achieving these outcomes appeared to be clear and
reasonable. The following paragraphs summarize our findings:

 Planned outcome: Less fraud, waste, and error in Medicare and Medicaid.
While the Health Care Financing Administration?s (HCFA) performance report
and plan indicate that it is making some progress toward achieving its
Medicare program integrity outcome, tracking progress was difficult because
of continual changes in its goals. HCFA had no program integrity goal for
Medicaid for fiscal year 2000 but has since added a developmental goal. A
major HCFA strategy to tackle the problem of fraud- the addition of new
goals- appears to be reasonable. However, a number of the new goals outlined
the need to establish a process to address problems, and in some cases,
targets to measure progress had not yet been developed.

 Planned outcome: Beneficiaries receive high- quality nursing home
services. HCFA?s performance report and plan indicate that it continues to
make progress toward ensuring that nursing home residents receive
highquality care, but its three goals under this outcome are surprisingly
narrow in light of its broader agenda, embodied in about 30 ongoing
initiatives to improve the quality of care in America?s nursing homes. The
lack of recognition of the initiatives is even more surprising in light of
congressional direction that HCFA establish benchmarks and track Results in
Brief

Progress and Strategies

Page 3 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

progress in implementing each of the initiatives. 4 HCFA?s strategies for
achieving this outcome appear to be clear and reasonable.

 Planned outcome: Poor and disadvantaged families and individuals become
self- sufficient. Similar to last year?s review, we could not fully assess
the Administration for Children and Families? progress in achieving this
outcome because the agency again was unable to provide timely performance
data for many of the related measures. The little data that were available
for fiscal year 2000 portray mixed success, and newly available fiscal year
1999 data generally indicated a similar picture. Few Administration for
Children and Families? strategies for achieving this outcome are directly
linked to specific performances that fell below fiscal year 2000 or 1999
target levels, and the strategies do not address in detail reporting delays
from program partners, as we urged in last year?s review.

 Planned outcome: Improved prevention of infectious diseases, including
vaccine- preventable diseases. The performance reports and plans of HHS
components indicate that they have made mixed progress toward achieving the
15 infectious disease prevention goals associated with this outcome, but in
some cases data to measure progress were unavailable. Several agencies
acknowledged their problems with data time lags, and some pointed to trend
data to suggest that they are getting closer to their targets. While the
components? strategies for achieving some goals are clear and reasonable,
they do not always discuss how they plan to attain unmet goals, and some
strategies are not directly tied to goal attainment.

 Planned outcome: Reduced use of illegal drugs. The Substance Abuse and
Mental Health Services Administration?s (SAMHSA) performance report and plan
indicate that it has made some progress in achieving this outcome. While it
continues to have problems collecting data for about half of its 80 goals,
SAMHSA reported that it met or exceeded its target for nearly 90 percent of
the goals for which it had data. Delays in reporting performance data were
attributed to time lags in data collection, analysis, and reporting by
states. It plans to have final data for most performance goals later in
2001. SAMHSA did not report strategies for achieving several planned goals.
Thus, while it cited measurable targets and time frames for achieving its
prevention and treatment programs, it omitted details about how these
programs will attain their targets.

 Planned outcome: Public has prompt access to safe and effective medical
drugs and devices. The Food and Drug Administration?s (FDA) performance
report and plan indicate that it has made significant progress

4 HCFA now refers to the nursing home initiatives as the Nursing Home
Oversight Improvement Program.

Page 4 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

in achieving this outcome. In last year?s assessment, we reported that
performance data were unavailable for the majority of FDA?s goals. In
contrast, the fiscal year 2000 performance report provides outcome data on
nearly all goals, and FDA reported that it met or exceeded most of its
targets. FDA?s strategies for achieving this outcome are clear and
reasonable. When FDA did not meet a goal, it generally provided an
explanation and discussed strategies for improving future performance,
including human capital strategies.

Although the current reports and plans of HHS components were generally
similar to last year?s, some changes have improved their usefulness and
readability. For example, the Centers for Disease Control and Prevention
(CDC) made extensive revisions to more effectively communicate and link its
goals, measures, and targets with the strategies for achieving them. The
Administration for Children and Families and FDA added summaries that
provide a helpful overview, and HCFA generally made its narrative discussion
more concise. Finally, FDA made strong use of graphics this year, and HCFA
introduced graphics into its report and plan. However, several key
weaknesses that we noted last year remain. For example, time lags in the
availability of performance data continue to be a major problem for the
Administration for Children and Families and SAMHSA and affect some goals
for other HHS components such as HCFA, CDC, and FDA. Although the
Administration for Children and Families did not present specific strategies
to overcome these delays, SAMHSA said it is working with states to improve
its performance reporting, as directed by the Congress. It may not always be
realistic to expect the availability of complete data at the same time
annual performance reports and plans are issued, but trends will become
apparent as the number of performance reports and plans grows with each
passing year. CDC and the Health Resources and Services Administration have
made progress in addressing our past concerns about data verification.
However, this issue remains an unaddressed problem for HCFA?s nursing home-
related goals and for SAMHSA. Finally, tracking HCFA?s reporting of program
integrity issues continues to be problematic, making it difficult to fully
report on progress.

HHS does not have departmental performance goals related to two of the
governmentwide management challenges we have identified- human capital and
information security. However, several HHS components have included these
goals and measures in their plans, and some cite progress. For example,
HCFA?s performance report and plan indicated that it is making progress both
in its workforce planning effort and its initiative to Comparison of Reports

and Plans Management Challenges

Page 5 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

update information security policies. In general, HHS could do a better job
of illustrating how it is using human capital strategies to improve
performance. We have identified five other major management challenges
facing HHS, four of which were encompassed in key outcomes discussed
earlier- Medicare program integrity, nursing home quality of care, economic
independence for families, and medical product safety. 5 Regarding the fifth
challenge- ensuring a well- designed and administered Medicare program- HCFA
is taking steps to reduce the gap between the current and targeted skill
levels of its employees.

HHS reviewed a draft of this report and found it to be an accurate and
complete assessment of the key outcomes and major management challenges
contained in the GPRA reports of its components. We have addressed its
specific comments in the corresponding sections of the report.

GPRA is intended to shift the focus of government decisionmaking,
management, and accountability from activities and processes to the results
and outcomes achieved by federal programs. New and valuable information on
the plans, goals, and strategies of federal agencies has been provided since
federal agencies began implementing GPRA. Under GPRA, annual performance
plans are to clearly inform the Congress and the public of (1) the annual
performance goals for agencies? major programs and activities, (2) the
measures that will be used to gauge performance, (3) the strategies and
resources required to achieve the performance goals, and (4) the procedures
that will be used to verify and validate performance information. These
annual plans, issued soon after transmittal of the president?s budget,
provide a direct link between an agency?s longer- term goals and mission and
its day- to- day activities. 6 Annual performance reports are to report
subsequently on the degree to which performance goals were met. The issuance
of the agencies? performance reports, due by March 31, represents a new and
potentially more substantive phase in the implementation of GPRA- the
opportunity to assess federal agencies? actual performance for the prior
fiscal year and

5 Major Management Challenges and Program Risks: Department of Health and
Human Services (GAO- 01- 247, Jan. 2001). 6 The fiscal year 2002 performance
plan is the fourth of these annual plans under GPRA. Background

Page 6 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

to consider what steps are needed to improve performance and reduce costs in
the future. 7

HHS has a broad and challenging mission that touches the lives of Americans
from every economic stratum: enhancing the health and wellbeing of all
Americans by

 providing for effective health and human services, and

 fostering strong, sustained advances in the sciences underlying medicine,
public health, and social services.

With a budget of $376 billion and a direct workforce of 59,000, HHS
administers some 300 health and social programs, including Medicare,
Medicaid, the State Children?s Health Insurance Program, Temporary
Assistance for Needy Families, and food and drug safety. HHS? programs often
require operating components to coordinate with partners such as state,
local, and tribal governments; grantees; and contractors. For example, HCFA
shares responsibility with states for administering Medicaid- a program that
provides health care to certain low- income persons. HCFA also monitors the
approximately 50 Medicare contractors that pay claims for the program?s
elderly and disabled beneficiaries and that establish local medical coverage
policies. SAMHSA administers a grant program to states for treatment and
prevention services for persons at risk of or actually abusing alcohol or
other drugs. Finally, the Administration for Children and Families partners
with states to provide support to needy children and transition their
parents to work.

7 The fiscal year 2000 performance report is the second of these annual
reports under GPRA.

Page 7 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

This section discusses our analysis of HHS? performance in achieving its
selected key outcomes and the strategies it has in place- including human
capital and information technology- for accomplishing these outcomes. 8 We
also provide information drawn from our prior work about the credibility of
the agency?s performance information.

While HCFA?s performance report and plan indicate that it is making some
progress toward achieving its Medicare program integrity outcome, progress
is difficult to measure because of continual goal changes that are sometimes
hard to track or that are made with insufficient explanation. Of the five
fiscal year 2000 program integrity goals it discussed, HCFA reported that
three were met, a fourth unmet goal was revised to reflect a new focus, and
performance data for the fifth will not be available until mid- 2001. HCFA
plans to discontinue three of these goals. Although the federal share of
Medicaid is projected to be $124 billion in fiscal year 2001, HCFA had no
program integrity goal for Medicaid for fiscal year 2000. HCFA has since
added a developmental goal concerning Medicaid payment accuracy.

One of HCFA?s key Medicare program integrity goals is to pay claims properly
the first time. Therefore, HCFA has set the performance goal of reducing
improper payments as a priority for Medicare. The central measure of
progress for this goal is the rate of improper fee- for- service payments,
which is now estimated by the HHS OIG. HCFA will assume responsibility for
measuring this error rate in fiscal year 2002. HCFA reported meeting its
fiscal year 2000 error rate target of 7 percent with a rate of 6.8 percent.

HCFA reported that it did not meet its fiscal year 2000 goal to perform
medical reviews of 100 million claims, and it is difficult to determine
whether its revised goal is being continued. 9 In its narrative, HCFA

8 Key elements of modern human capital management include strategic human
capital planning and organizational alignment; leadership continuity and
succession planning; acquiring and developing staffs whose size, skills, and
deployment meet agency needs; and creating results- oriented organizational
cultures.

9 In fiscal year 2000, its contractors processed about 900 million claims.
Assessment of HHS?

Progress and Strategies in Accomplishing Selected Key Outcomes

Fraud, Waste, and Error in Medicare and Medicaid

Page 8 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

explained that it revised its goal to focus on improving the accuracy and
appropriateness of medical reviews rather than simply to increase the number
of reviews conducted. But later, in a chart describing changes in GPRA
goals, HCFA noted that this goal was subsumed in a fiscal year 2001 goal to
improve the effectiveness of program integrity activities through successful
implementation of this and nine other initiatives contained in the
Comprehensive Plan for Program Integrity. The current performance report and
plan only cursorily mention the Comprehensive Plan initiatives but indicate
that the goal will be reached in fiscal year 2001 and therefore will not be
continued.

HCFA discontinued two of its fiscal year 2000 performance goals for which it
reported making progress. Although data will not be available until mid-
2001 on its discontinued goal to decrease the improper payment rate for home
health services, HCFA reported ?expected achievement? of its 10- percent
target as justification for dropping the goal. Nevertheless, this area
remains on the HHS OIG?s list of major management challenges. HCFA also
discontinued, with little explanation, the goal of increasing the ratio of
dollars recovered through the audit process to dollars spent on auditing
activities. It reported it dropped the goal because of data source concerns
(which it did not discuss) but also said it is examining other ways to
measure progress on this issue. HCFA nevertheless reported that it exceeded
its fiscal year 2000 target for this goal. In commenting on a draft of this
report, HHS noted that HCFA has discontinued certain goals because they are
ultimately part of the overall error rate measure and do not reflect the
accomplishments of HCFA?s overall program integrity efforts.

We have previously reported on two general weaknesses that hinder HCFA?s
efforts to ensure proper payments of Medicare claims: outmoded information
systems and weak financial management procedures. 10 Without effective
systems, HCFA is not well positioned for sound financial or programmatic
management. HCFA has taken steps to modernize its systems and strengthen its
financial management but many challenges remain. For example, HCFA?s fiscal
year 2000 performance report notes progress made in addressing weaknesses
related to its financial information, such as improvements in controls over
Medicare contractor

10 GAO- 01- 247, Jan 2001.

Page 9 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

data. 11 However, HCFA is still not in compliance with the Federal Financial
Management Improvement Act (FFMIA) and continues to have material weaknesses
related to reliability and documentation of its financial information. 12
HCFA acknowledges that its ability to fully address underlying financial
weaknesses remains impaired because it lacks a fully integrated financial
management system.

Despite repeated instances of noncompliance and the need for an integrated
general ledger system to address major financial management weaknesses,
HCFA?s performance report does not include specific goals and targets for
achieving compliance with FFMIA, a situation we also noted in prior
performance plan reviews. While HCFA?s Chief Financial Officer Comprehensive
Plan for Financial Management includes goals for developing an integrated
general ledger system, this document and the related costs and resources for
implementing the system are not referred to in HCFA? s performance report or
plan.

HCFA?s strategies for achieving many goals related to minimizing fraud,
waste, and error appear to be clear and reasonable. One important HCFA
strategy is to establish new goals and revise existing goals that will
enhance program integrity efforts. Recognizing limitations in the usefulness
of the national Medicare error rate as a management tool, HCFA?s strategy is
to develop a subnational error rate. Thus, it established a fiscal year 2001
goal of developing a separate error rate for each Medicare claims contractor
and of implementing a provider compliance rate. It is also developing a
method for estimating a fraud rate among providers within its contractors?
service areas. Finally, HCFA introduced a fiscal year 2002 goal intended to
improve the provider enrollment process by ensuring that only qualified and
legitimate providers are permitted to participate in Medicare. 13

Because many of the baselines and measures for these new and revised goals
are under development, HCFA?s intended performance regarding them is
unclear. For example, HCFA?s fiscal year 2002 plan contains a

11 HCFA did achieve a ?clean? opinion on its fiscal year 2000 financial
statement, a Medicare contractor performance goal. 12 Medicare Financial
Management: Further Improvements Needed to Establish Adequate Financial
Control and Accountability (GAO/ AIMD- 00- 66, Mar. 15, 2000).

13 Medicare: HCFA to Strengthen Medicare Provider Enrollment Significantly,
but Implementation Behind Schedule (GAO- 01- 114R, Nov. 2, 2000).

Page 10 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

developmental goal to improve its oversight of Medicare fee- for- service
contractors. 14 Its fiscal year 2002 target is to build on progress achieved
in fiscal years 1999, 2000, and 2001. Similarly, HCFA?s fiscal year 2001 and
2002 plans include a developmental goal to help states conduct Medicaid
payment accuracy studies in order to measure and ultimately reduce Medicaid
payment error rates. The fiscal year 2001 target is to establish the
feasibility of conducting pilot projects within states and, for fiscal year
2002, to assess the pilots initiated by two states. 15

With respect to one fiscal year 2001 goal, HCFA notes human capital and
information technology limitations but does not discuss strategies for
addressing them. Thus, HCFA reports that because of limited resources and
funding, it only audits a small percentage of providers regarding credit
balance recoveries and that it lacks the database needed to track provider
activity in this area. 16

In prior reviews of this key outcome, we noted that HCFA did not adequately
address the need for coordination with other organizations. While HCFA
includes a brief coordination section in the individual goal narratives, it
does not consistently provide details about planned coordination strategies.
For example, one coordination strategy reads:

?We will continue to work with our partners in conducting our everyday
business of ensuring Medicare claims are paid properly.?

HCFA?s performance report and plan indicate that it continues to make
progress toward its outcome of ensuring that nursing home residents receive
high- quality care but its focus on just 3 goals under this outcome is

14 For years, HCFA?s contractor evaluation process lacked the consistency
that agency reviewers needed to make comparable assessments of contractor
performance. HCFA reviewers had few measurable performance standards and
little agencywide direction on monitoring contractors? payment safeguard
activities. HCFA now is refocusing contractor performance evaluation to
achieve a risk- based, consistent national approach to contractor review.
See Medicare Contractors: Despite Its Efforts, HCFA Cannot Ensure Their
Effectiveness or Integrity (GAO/ HEHS- 99- 115, July 14, 1999) and Medicare
Contractors: Further Improvement Needed in Headquarters and Regional Office
Oversight (GAO/ HEHS- 00- 46, Mar. 23, 2000).

15 HCFA plans to work with two states to conduct payment accuracy studies to
help refine methodologies and to assess the feasibility of constructing a
single methodology that could be used by all states.

16 See Medicare: HCFA Could Do More to Identify and Collect Overpayments
(GAO/ HEHS/ AIMD- 00- 304, Sept. 7, 2000). High- Quality Nursing

Home Services

Page 11 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

surprisingly narrow, given the broad range of its approximately 30
initiatives to improve the quality of care in America?s nursing homes. The
lack of recognition of the Nursing Home Oversight Improvement Program
initiatives is even more notable because the Senate Committee on Aging
requested that HCFA establish benchmarks and track progress in implementing
each of these initiatives. In commenting on a draft of this report, HCFA
noted that its performance goals are not intended to be a comprehensive list
of its performance measures.

On the basis of interim data, HCFA reported that the prevalence of
restraints used in nursing homes decreased during fiscal year 2000. This
decrease represents the second consecutive year in which the goal of
reducing the use of restraints was surpassed. Final data were expected after
the publication of HCFA?s performance report. Regarding its second goal,
HCFA reported, for the first time, the prevalence of nursing home residents
suffering from pressure sores (bedsores) and established futureyear
performance targets for reducing their prevalence.

HCFA reported making progress toward its third goal of modifying the survey
and certification budgeting process to develop national standard measures
and costs. Once developed, these standards can be used to more effectively
price each state?s survey workload and to develop workload expectations for
each state. However, when we compared HCFA?s current and prior- year plans
for implementing this new budget methodology, we determined that the
modification will likely take HCFA longer to implement than it planned. For
instance, although its earlier plan indicated that its price- based
methodology would be complete in fiscal year 2001, its current- year plan
shows that future- year targets for this goal are yet to be determined.
Nevertheless, in fiscal year 2001, HCFA said it will allocate budget
increases to states with unit survey hours that do not exceed 15 percent
above the combined national average for nursing home surveys.

HCFA also eventually plans to use the standards for setting state
performance measures to assess the quality of nursing home surveys performed
by each state. As we noted in last year?s report, the critical step of
assessing states? performance could begin sooner if HCFA used existing data.
For instance, one of HCFA?s regional offices has analyzed data for several
years to help evaluate the performance of state survey agencies in its
region in areas such as whether states vary the timing of surveys to ensure
that nursing homes are unable to predict the date of their next survey. In a
report issued in September 2000, we highlighted HCFA?s commitment to begin
using data currently available to compile periodic

Page 12 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

reports on state performance and to supplement these reports with on- site
work to assess state performance. 17

Data inconsistencies we and the HHS OIG identified raise questions about the
accuracy of HCFA?s information on the prevalence of restraint use and
pressure sores. However, HCFA did not note any concerns about the
reliability of the On- Line Survey and Certification Reporting (OSCAR)
System database, nor did it discuss the concerns about minimum data set
accuracy raised by the HHS OIG. Our prior reports on nursing home quality
have noted the considerable variation across states in the reporting of
nursing home deficiencies in OSCAR- a situation that suggests some states
may be better than others at identifying problems. 18 The HHS OIG recently
found several problems related to the use of the minimum data set, including
differences between information on residents contained in the data set and
data maintained in the residents? medical records. 19 We also noted last
year that HCFA recognized the need to be cautious with its use of data in
the minimum data set until it assesses the data set?s accuracy and
completeness. 20 HCFA intends to award a contract this year to begin minimum
data set validation work in 2002. In commenting on a draft of this report,
HCFA said it found our discussion of this proposed validation contract
inconsistent with our finding that it had not discussed concerns about
minimum data set accuracy in its GPRA report. We believe that HCFA?s GPRA
report should have acknowledged the proposed validation contract since it is
directly relevant to a discussion of the reliability of data used to measure
progress in achieving goals under the nursing home quality outcome. HCFA
also expressed concern about the reliability of the HHS OIG?s findings on
minimum data set accuracy. The fact that HCFA has a proposed validation
contract suggests that it, too, has concerns about minimum data set
accuracy.

Despite its narrow focus on only three goals, HCFA?s strategies to achieve
them are generally clear and reasonable. For example, to decrease the

17 Areas to be measured include survey timing, deficiency documentation, and
complaint investigations. Nursing Homes: Sustained Efforts Are Essential to
Realize Potential of the Quality Initiatives (GAO/ HEHS- 00- 197, Sept. 28,
2000).

18 Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better
Ensure Quality (GAO/ HEHS- 00- 6, Nov. 4, 1999). 19 HHS OIG, Nursing Home
Resident Assessment: Resource Utilization Groups, OEI- 02- 9900041
(Washington, D. C.: HHS, Dec. 2000). 20 GAO/ HEHS- 00- 127R, June 30, 2000.

Page 13 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

prevalence of pressure sores, HCFA is working to improve surveyors? ability
to assess residents? conditions by conducting educational seminars for
surveyors and adding a new investigative protocol to help surveyors detect
pressure sores during a survey. It is also strengthening enforcement
activities against homes that fail to prevent avoidable pressure sores.
However, HCFA?s discussion of its strategy to ensure that nursing home
residents are not unnecessarily restrained is incomplete. It notes that it
relies on the state survey and certification process but does not discuss
the role of outside groups, which also have sponsored a large number of
provider and consumer education projects to demonstrate ways to reduce
restraint use. 21

To improve the overall management of the survey and certification process,
HCFA?s strategy has been to conduct studies to identify significant
differences in survey time and resource utilization among state survey
teams. HCFA plans to research these variations, determine which have the
strongest relationship to cost and performance, establish standard measures
of cost and workload, and develop future survey and certification budgets on
the basis of standard prices. HCFA?s new budgeting approach will address the
importance of human capital by ensuring that states have an appropriate
number of qualified surveyors. Disparities in staffing might have been a
contributing factor to deficiencies in state oversight activities. During
our 2000 review of HCFA?s implementation of the Clinton Administration?s
nursing home initiatives, we noted that a number of states had hired
additional surveyors to promote more timely complaint investigations as well
as to ensure that nursing homes are inspected an average of every 12 months.
Furthermore, although HCFA did not address this in its plan, it has taken
steps to improve its information technology systems to enhance oversight of
nursing home quality of care. For instance, HCFA is in the process of
redesigning its OSCAR database to make it easier to generate analytical
reports.

21 As part of a survey, state or federal surveyors observe each nursing
home?s use of restraints and issue a deficiency citation against a home that
restrains a resident without clear medical reason.

Page 14 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Similar to last year, the Administration for Children and Families (ACF)
reported that it lacked fiscal year 2000 performance data for 18 of the 26
measures associated with programs whose performance is critical in reaching
this key outcome. 22 As a result, we were unable to fully assess ACF?s
progress. ACF largely attributes missing performance data to the time lag in
receiving and validating data reports from its program partners, including
states and localities. Specifically, no fiscal year 2000 performance data
were reported for the Temporary Assistance for Needy Families (TANF), Child
Support Enforcement, Child Care, and Refugee Resettlement programs.

The limited performance data that were available in ACF?s report and plan
indicate that its progress has been mixed. ACF reported that it achieved its
target for four of the eight measures that had fiscal year 2000 performance
data, including two measures related to the Developmental Disabilities
Employment and Housing programs and measures related to increasing
nondiscriminatory access to and participation in HHS programs. Target levels
that ACF reported not meeting in fiscal year 2000 include two measures
associated with increasing the number of HHS grantees and providers found to
be in compliance with title IV in limited English proficiency reviews and
investigations. For measures without fiscal year 2000 performance data,
fiscal year 1999 performance data, which are now available, showed that 7 of
16 measures met or exceeded their targets and 2 measures came very close to
meeting their targets. 23

ACF may not be positioned to meet some future target levels, which appear to
be set beyond what it can reasonably expect to achieve. Some measures, for
example, have shown a recent decline and ACF may continue to not meet its
targets for these in the future. These measures include (1) the earning
gains rate and the employment retention rate under the TANF program; (2) the
number of refugees becoming employed, the

22 In addition to ACF, our review also included related goals and
performance measures of HHS? Office for Civil Rights (OCR). ACF and OCR use
the term ?measures? to describe what other HHS components refer to as goals.
ACF uses the term ?goal? to refer to the overall outcome of improving self-
sufficiency of families and individuals. ACF divides this goal into four
objectives: (1) increase employment, (2) increase independent living, (3)
increase parental responsibility, and (4) increase affordable child care.
One of OCR?s goals is to increase nondiscriminatory access to and
participation in HHS programs. OCR divides this goal into six objectives,
two of which we addressed in our review.

23 Last year, we reported that HHS met the targets for four of the five
measures for which fiscal year 1999 performance data existed. Self-
Sufficiency for Poor

and Disadvantaged Families and Individuals

Page 15 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

number of refugee cash assistance cases closed because the recipient became
employed, and the number of 90- day job retentions under the Refugee
Assistance program; and (3) the cost- effectiveness ratio of the process to
collect medical and financial support under the Child Support Enforcement
Program. Other measures, while showing recent improvement, may not meet
their targets in the future, including the proportion of states that meet
the TANF two- parent work participation rate of 90 percent and the number of
children served by Child Care and Development Fund subsidies. In commenting
on a draft of this report, ACF suggested that we favored a downward revision
of the above targets. This was not the case. We recognize that ACF officials
have encouraged programs, such as TANF, to intentionally set ambitious
targets for some goals. Our comments were only meant to alert the Congress
to the fact that certain goals may not be achieved in the future,
information that ACF should have provided to assist congressional
decisionmaking. For the examples cited, GAO relied on the multi- year data
presented in ACF?s fiscal year 2002 performance plan, not on a single year?s
performance as suggested by ACF.

Few ACF strategies for achieving this outcome (1) were directly linked to
specific performance that fell below fiscal year 2000 or 1999 target levels
or (2) were aimed at overcoming ACF management challenges identified by us
or the HHS OIG. Because it administers most of its programs in conjunction
with states and/ or other entities, ACF involves its partners in
establishment of performance measures to help ensure their achievement. For
example, other ACF strategies include providing technical assistance,
disseminating the results of program evaluations and other research, and
using rewards and penalties to improve performance. Finally, the fiscal year
2002 plan indicates that ACF will continue its ongoing evaluation of various
aspects of welfare reform; in particular, ACF plans to evaluate performance
measures related to increasing parental responsibility and increasing
affordable child- care.

ACF?s fiscal year 2002 plan offers no concrete strategy to overcome the time
lag in receiving and validating performance data from program partners, and
it generally does not report on the results of data validation efforts.
ACF?s report acknowledges that such time lags make it difficult to provide a
comprehensive summary of fiscal year 2000 performance until later in fiscal
year 2001. 24 ACF indicated it would develop a plan with HHS

24 ACF expects that fiscal year 2000 data will be available for the
remaining measures with target levels between April 2001 and December 2001.

Page 16 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

and the Office of Management and Budget in fiscal year 2001 for reducing the
delay in the availability of state administrative data, where appropriate.
Until this plan is developed and implemented, however, obtaining timely data
for measures pertaining to helping individuals and families become self-
sufficient will continue to impede assessments of ACF?s performance. In
commenting on a draft of this report, ACF cited grant- reporting timeframes
as a constraint in the timely availability of performance data. The fact
remains, however, that ACF offered no concrete strategy to overcome the
reporting time lags. By indicating that it will work with the Office of
Management and Budget to reduce delays in the availability of administrative
data, ACF underscores the need for more timely information. We do point out
in our conclusions, however, that the issue of data lags may become less
critical as trends emerge from data over longer time periods.

ACF broadly discusses its human capital and information technology
strategies in its fiscal year 2000 report and 2002 plan. ACF reported that
it did not achieve an increase in the manager- to- staff ratio- its one
human capital performance measure in fiscal year 2000- because of limits on
hiring new staff and on reducing the number of managers already on board.
However, ACF did meet its one performance measure related to information
technology in fiscal year 2000 by replacing an outmoded

?audit resolution tracking process? with an updated, integrated system. The
fiscal year 2002 plan says little about how ACF intends to use human capital
and information technologies to achieve this key outcome. In commenting on a
draft of this report, ACF noted the use of human capital strategies such as
training employees in marketing, negotiating, and consulting; using and
improving automated technology, databases, and electronic communications;
and implementing team- based work procedures. In the report, however, ACF
does not tie such strategies to specific TANF- related measures with targets
that might be set too high. Nor does it indicate how these strategies will
help overcome problems, such as the 26 percent shortfall found in fiscal
year 1999 in states that meet the TANF two parent families work
participation rate. Similarly, we believe that ACF?s reference to its
information technology investments presents a broad discussion of the role
of information technology.

We noted in January 2001 that sweeping changes brought about by welfare
reform make better information systems and data collection necessary to
improve program management and to help HHS measure its state partners?

Page 17 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

performance in this area. 25 In particular, we highlighted the importance of
addressing the need for states to have access to information across states
on individuals? receipt of welfare to enforce the 5- year TANF time limit.
26 Because adequate automated systems are critical to the success of welfare
reform, we recommended that HHS work with other federal agencies, including
the Departments of Agriculture and Labor, to address issues surrounding
state automated data systems. ACF reported that it continues to work on
correcting performance information and strengthening partnerships with
states and grantees and that it gives high priority to creating mature data
collection strategies. ACF also noted that it is working with other HHS
components to assess unmet data needs and is committed to increasing its
investment in data collection and information systems. The fiscal year 2000
report does not, however, offer targeted strategies for improving states?
automated systems, including the capacity to support enforcement of the 5-
year TANF time limit. In commenting on a draft of this report, ACF pointed
out that it (1) reported to Congress in 1997 that additional program
authority and resources would be required to implement a tracking system to
enforce TANF time limits; (2) developed a system that potentially will allow
states to track the 5- year limit; and (3) is working with states to
identify their automated system needs. The ACF report, however, did not
contain adequate information on these strategies that would allow us to
comment on the extent to which they address our past concerns.

The performance reports and plans of HHS components indicate that they have
made mixed progress toward achieving the 15 infectious disease prevention
goals associated with this outcome and, in some cases, that data to measure
progress are unavailable. 27 The goals, many of which have multiple targets,
include reductions in HIV, AIDS, other sexually transmitted diseases, and
vaccine- preventable diseases. The five HHS components responsible for
implementing infectious disease prevention goals are the Centers for Disease
Control and Prevention (CDC), HCFA,

25 Major Management Challenges and Program Risks: Department of Health and
Human Services (GAO- 01- 247, Jan. 2001). 26 Welfare Reform: Improving State
Automated Systems Requires Coordinated Federal Effort (GAO/ HEHS- 00- 48,
April 27, 2000). 27 HHS has numerous goals related to the prevention of
infectious diseases. We focused on 15 goals that most directly related to
this outcome. Prevention of Infectious

Diseases, Including Vaccine- Preventable Diseases

Page 18 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

the Health Resources and Services Administration (HRSA), the Indian Health
Service (IHS), and the National Institutes of Health (NIH).

Three of these agencies have goals to reduce vaccine- preventable diseases.
Provisional data indicate that, for most targeted diseases, CDC met its goal
of achieving a 90- percent vaccination rate for 2- year- olds. It provided a
reasonable explanation of why the target for the diphtheria, tetanus, and
pertussis vaccine was missed by a few percentage points. IHS also came close
to meeting its children?s immunization completion rate. HCFA?s goal to
increase the rate of fully immunized Medicaid 2- year- olds is
statespecific, and measurement methods are still being developed. CDC, HCFA,
and IHS generally did not yet have data to assess their progress in
increasing pneumococcal pneumonia and influenza vaccination rates among the
elderly, but interim progress data were cited.

A data lag impedes the measurement of progress toward reducing the incidence
of HIV and AIDS. Trend data indicate that CDC and HRSA are making progress
in reducing perinatal transmission of HIV. Relying on process descriptions,
NIH reports progress toward achieving its goal of developing an AIDS vaccine
by 2007. CDC reported mixed progress toward its goals of reducing sexually
transmitted diseases. In general, fiscal year 2000 data were not available
at the time performance reports were published, but fiscal year 1999 data
indicated in different target populations more progress toward reducing some
sexually- transmitted diseases (congenital syphilis) than others
(chlamydia).

Data lags are common for many prevention goals, and it may be unrealistic to
expect HHS to include complete data at the same time it issues its annual
performance report and plan. As HHS continues to report its results, we will
in turn receive more accumulated trend data to portray its progress. Data
verification and validation remain important issues. The HHS agencies with
infectious disease prevention goals tend to provide general information on
the credibility of their performance measures and of their methodological
approaches. For example, HRSA notes how the electronic submission of data,
starting in fiscal year 2000, will address the reliability and validity
concerns we raised previously. All of these agencies discuss measurement in
the context of specific goals, but they do not always discuss why particular
goals may be poorly measured. However, CDC?s report broadly discusses the
measurement issues relevant to particular prevention goals, such as an
account of HIV surveillance efforts. Similarly, HCFA describes the surveys
it uses for assessing vaccination rates, including their limitations, and
IHS explains the criteria it used to select its prevention indicators.

Page 19 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

While the components? strategies for achieving some goals are clear and
reasonable, they do not always include information about how they plan to
attain unmet goals, and some strategies are not directly tied to goal
attainment. With respect to specific goals or groups of goals, CDC often
includes an informative discussion of its performance strategies. For
example, it summarizes how it plans to eradicate syphilis in the United
States. Furthermore, CDC states some of its goals in terms of the strategy
to attain them, such as using ?screening? and ?treatment? in the goal
descriptions for sexually transmitted diseases. HCFA includes a detailed
discussion of strategies to foster higher immunization rates among seniors,
including sponsoring outreach projects in health care venues and
implementing routine procedures for providing certain immunizations without
direct physician involvement. Its discussion of the goal of increasing the
percentage of 2- year olds who are fully immunized focuses primarily on
outreach and increasing enrollment as ways to effect the increases.

The IHS report explains why it did not achieve certain goals but does not
always articulate strategies for overcoming problems that impede progress.
IHS noted, for example, that complex immunization schedules and incomplete
tracking due to multiple sources of health care were a problem in meeting
its goals. IHS?s report does discuss strategies for meeting its goals for
childhood immunizations, but it discusses adult vaccination levels chiefly
in terms of baseline and target rates, not in terms of vaccinating more
people. Rather than identifying ways of vaccinating more people, however, it
discusses establishing the appropriate baseline and adjusting the targets.
Similarly, when CDC does not meet a goal, it does not always discuss
specific strategies for attaining that goal. NIH?s strategies also are
general rather than goal specific. Thus, its report highlights a number of
broad strategies related to its overall mission, such as providing
scientific leadership, facilitating the development of healthrelated
products, and collaborating and coordinating with others.

When the issues of human capital, information technology, the contributions
of others, and program evaluations were included in the GPRA reports and
plans of HHS components, their importance in helping to achieve goals was
only discussed in general terms. Thus, while both HCFA and HRSA discuss
human resources, they do not talk about them in the context of particular
infectious disease prevention goals. Furthermore, IHS simply notes that
human resource development is an essential component of its performance
planning and management and provides some details about its activities in
this area. Similarly, CDC, HCFA, and HRSA acknowledge generally the
importance of information technology as

Page 20 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

it relates to their missions and goals. In contrast, IHS has specific
measures addressing the development of improved automated data capabilities
that are designed, in part, to improve performance measurement and GPRA
compliance. While HHS components discuss the contributions of others by
referring to ?partnerships and coordination with other organizations,? IHS
specifically notes its efforts to address HIV and vaccine- preventable
infectious diseases through an agreement with CDC. Finally, regarding the
use of program evaluations prepared by each component or others, the
discussions usually are not related to specific infectious disease
prevention goals.

SAMHSA?s performance plan and report indicates that it has made some
progress in achieving this outcome. While it continues to have problems
collecting data for about half of its 80 goals, SAMHSA reported that it met
or exceeded its target for nearly 90 percent of the goals for which it had
data. Delays in reporting performance data were attributed to time lags in
data collection, analysis, and reporting by states and the relatively large
number of targets being measured. SAMHSA plans to have final data for most
performance goals later in 2001.

SAMHSA reported that it met many of the substance abuse and prevention
treatment goals for which data were available. For example, SAMHSA indicated
that it exceeded its target of increasing the number of states to 19 that
voluntarily report critical outcome performance measures in Substance Abuse
Prevention and Treatment Block Grant applications, as 24 states voluntarily
reported at least partial outcome data. It also indicated that the number of
states that incorporate needs assessment data increased from 26 states in
fiscal year 1999 to 34 states in fiscal year 2000, meeting its fiscal year
2000 target. The incorporation of needs assessment data is critical for
prevention planning, resource allocation, and selection of appropriate
prevention strategies. Finally, SAMHSA reported that the percentage of
states that use funds in each of six prevention strategy areas, which track
progress in addressing the substance abuse prevention needs of populations,
met the fiscal year 2000 target of 90 percent. SAMHSA gave a credible
explanation for not meeting another goal related to the Substance Abuse
Prevention and Treatment Block Grant program- continuing dialogue over the
appropriateness of the targets- and indicated that the type and form of
performance reporting will be decided by fiscal year 2002.

SAMHSA?s performance report and plan indicate that it was far less
successful in reporting important state- level performance data on the Use
of Illegal Drugs

Page 21 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

effectiveness of substance abuse treatment services for fiscal year 2000.
States were to voluntarily report the percentage of substance abuse
treatment clients who had reduced substance abuse and criminal involvement,
had a permanent place to live, and were employed. However, fewer states than
SAMHSA anticipated reported this information, and some states used different
data collection methods to report information, raising questions about the
reliability of the data. Consequently, SAMHSA dropped these goals and will
develop new ones jointly with the states. Although development of goals will
continue, client- related outcome data cannot be collected until SAMHSA
complies with statutory requirements under the Children?s Health Act of
2000. The law requires SAMHSA to develop a plan, due by fiscal year 2002,
that gives states flexibility in reporting outcome data based on a common
set of performance goals, while preserving accountability. SAMHSA
anticipates that the new goals will be approved in fiscal year 2003 and that
collection and outcome measurement reporting will begin in fiscal year 2004.

SAMHSA?s performance report does not provide assurance that all information
contained in it is credible. Several performance measurements lack
discussions of the specific procedures used to verify and validate data in
the systems. For example, the description of data sources and validity of
data supporting the measurement on treating adult marijuana users notes that
the performance data were collected with standard instruments administered
to clients by trained interviewers. Another measurement to develop and apply
statistical models associated with client retention and outcomes under the
Wrap- Around Services program asserts that project records documenting
progress of statistical work are expected to be reliable. However, neither
performance measurement discusses how and by whom the validity assessments
are performed, the strengths and weaknesses of the data, or the external
factors that may affect data reliability.

In addition, SAMHSA did not report strategies for achieving several planned
goals. For example, it cites measurable targets and time frames for
achieving goals related to reducing the size of the drug treatment gap;
increasing employment and education, and lowering illegal activity for
graduates of treatment programs; and reversing the trend in marijuana use
among youth. However, it omits details about how its prevention and
treatment programs will attain these goals. Furthermore, SAMHSA describes
the role of human capital management and information technology strategies
but does not tie these activities to specific goals. For example, SAMHSA
expects to complete a workforce plan in August 2001 that includes
recommendations on ensuring that staffing levels are

Page 22 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

sufficient to manage program growth, maintain a well- trained workforce, and
provide a high- quality work life. It also plans to develop benchmarks for
best practices in government and nongovernment human capital management
processes and incorporate them into its workforce plan. The performance plan
also notes that SAMHSA has reorganized numerous functions and programs to
streamline operations and conserve program management and other resources.
SAMSHA also has invested in information technologies to enhance professional
resources. Several communications and data management system improvements
recently completed or under way include the redesign or conversion of
SAMHSA?s Web site, intranet, and grants management system.

Finally, SAMHSA?s report describes coordination with its partners and
stakeholders, including the states, CDC, the Department of Veterans Affairs,
NIH?s National Institute on Drug Abuse, and the Office of National Drug
Control Policy, to determine priorities and help formulate certain goals.

FDA?s performance report and plan indicate that it has made significant
progress toward achieving this outcome. While performance data were
unavailable for nearly 60 percent of its fiscal year 1999 goals, FDA
reported results for 17 out of 19 goals in its fiscal year 2000 performance
report. FDA reported that it met or exceeded 14 goals, did not meet 3 goals,
and lacked outcome data for 2 goals.

FDA reported making progress in meeting its goals for both the Human Drug
and the Medical Device programs. For the Human Drug program, FDA noted that
it had met several goals by streamlining its adverse drug event reporting
system, providing the public with improved labeling information on over-
the- counter drugs, and initiating collaborations with the scientific
community on assessing product quality and manufacturing processes through
the Product Quality Research Institute. This research institute is a first-
ever partnership between the Human Drug program and industry scientists to
conduct research in various aspects of the pharmaceutical development
process. The objective is to streamline the drug development and approval
process for industry and FDA while ensuring high product quality. The Human
Drug program reported initiating seven working groups to address key drug
regulatory issues, which surpassed its goal of beginning research on at
least three projects identified by the Product Quality Research Institute.
FDA included updated fiscal year 1999 data in its performance report, which
showed that the Human Drug program exceeded most of its goals with respect
to reviewing drug applications. Final performance data are not yet available
Access to Safe and

Effective Medical Drugs and Devices

Page 23 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

for multiple targets under a goal on reviewing standard new drug submissions
and generic drug applications. FDA expects to have these data by early 2002.
According to FDA, late reporting of outcomes generally occurs because of
time lags for reporting final data for premarket review goals.

Regarding the Medical Device program, FDA reported that it exceeded targets
for several goals on premarket device approval applications and surpassed a
target on inspecting domestic medical device manufacturing establishments
(at least 90 percent conformance with FDA requirements). Equally important
was that at least 97 percent of mammography facilities met inspection
standards, a target met in fiscal year 2000 and the previous fiscal year.
The high percentage of facilities meeting standards is expected to enhance
the quality of images, leading to more accurate interpretation by physicians
and, ultimately, improved early detection of breast cancer.

FDA?s report does not always instill confidence that its performance
information is credible. For example, for the Human Drug program, it did not
discuss the steps taken to verify and validate procedures for tracking the
number of pediatric drug studies FDA requested under the Food and Drug
Administration Modernization Act of 1997 (FDAMA) or inspections of drug
establishments, including medical gas re- packers. Similarly, the Medical
Device program did not discuss procedures used to verify and validate data
in its medical device adverse event reporting system, which, as we reported
in our last assessment, has experienced serious data management challenges
related to the quality of reporting, processing, and reviewing reports. The
report also did not describe procedures that were used to ensure data
integrity for other databases, such as the Center for Devices and
Radiological Health Field Data systems and the Field Accomplishments
Tracking System.

FDA?s strategies for achieving this outcome are clear and reasonable. When
FDA did not meet a goal, it generally explained why and discussed strategies
for improving future performance, including human capital strategies. For
example, the Medical Device program did not achieve its goal of inspecting
22 percent of manufacturers of class II and III domestic medical devices in
fiscal year 2000. According to FDA, the growth of the device industry, the
complexity of devices, and dwindling resources have resulted in lower
inspection coverage and higher violation rates. Initially FDA addressed this
shortfall by focusing enforcement actions on high- risk devices. However,
FDA now believes that resource limitations have put inspection coverage
below critical mass, so it is requesting an appropriated funding increase
for domestic inspections in fiscal year 2002.

Page 24 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Inspection of foreign medical device manufacturers is also reportedly very
low, and FDA is proposing a strategy to address the problem. While FDA
managed to meet its goal of inspecting 9 percent of foreign manufacturers of
class II and III medical devices, it expects the foreign workload to
increase and inspection coverage to decline. The Mutual Recognition
Agreement is one of the major initiatives introduced to assist in reducing
FDA?s workload. However, FDA says it cannot maintain foreign inspections or
successfully implement the agreement with current resources because it
expects European Union assessment bodies will require extensive training. As
a result, for fiscal year 2002, FDA is requesting budget authority for
foreign inspections to cover the cost of training associated with the Mutual
Recognition Agreeement.

While FDA did not explain why the Medical Device program fell significantly
short of its target on developing the Medical Device Surveillance Network
system, it did propose a strategy to achieve its target. FDA plans to use
fiscal year 2001 funding to increase user facility participation to target
levels and extend the program to other types of facilities, such as
ambulatory care surgical centers.

For the selected key outcomes, this section describes major improvements or
remaining weaknesses in HHS? (1) fiscal year 2000 performance reports
compared with its fiscal year 1999 reports, and (2) fiscal year 2002
performance plans compared with its fiscal year 2001 plans. It also
discusses the degree to which HHS? fiscal year 2000 reports and fiscal year
2002 plans address concerns and recommendations by the Congress, us, the HHS
OIG, and others.

For fiscal years 2001 and 2002, HCFA issued a single document integrating
the appropriate performance report with the current year?s revised
performance plan and the next year?s plan. With respect to the fraud
outcome, neither HCFA?s fiscal year 1999 report nor its fiscal year 2000
annual performance report provided a comprehensive list of the relevant
year?s performance goals, targets, and actual performance, making it
difficult to fully track goals and measure progress. For example, earlier we
Comparison of HHS?

Fiscal Year 2000 Performance Reports and Fiscal Year 2002 Performance Plans
With The Prior Year?s Reports and Plans for Selected Key Outcomes

Fraud, Waste, and Error in Medicare and Medicaid

Page 25 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

discussed the difficulty in tracking HCFA?s goal on medical review. HCFA
also acknowledged in both reports that timeliness of data is a challenge in
its analysis of performance data. For example, data are incomplete for the
goal of reducing the percentage of improper payments made under the Medicare
fee- for- service program in the fiscal year 1999 report and, as mentioned
earlier, for the goal of reducing the improper payment rate for home health
services in the fiscal year 2000 report.

HCFA has changed some of its performance goals and measures each year, which
makes it difficult to track its progress in reducing fraud, waste, and error
in Medicare and Medicaid. In both the fiscal year 2001 and 2002 annual
performance plans, goals are dropped, revised, subsumed into other goals,
and added. Two key weaknesses we identified in prior- year HCFA performance
plans are that goals were not consistently measurable and that the
strategies and resources needed to achieve these goals were not adequately
addressed. These problems continue. In some instances, HCFA is still
developing the baselines and appropriate measures. In others, HCFA states
generally that the accomplishment of a goal is the target and does not
explain in sufficient detail what its strategies are to ensure goal
accomplishment.

An improvement of the fiscal year 2002 plan over the prior plan is that the
goal narratives, which are included, are generally more concise and in many
cases include illustrative charts that indicate targets and previous
performance. Both performance plans reflect HCFA?s efforts to strengthen
coordination with other organizations and to enhance data verification and
validations. In some areas of performance, however, sufficient detail is not
consistently provided on coordination strategies- a problem we also noted
with the prior year?s performance plan. Regarding data issues, HCFA cites
and describes data sources for each goal and includes some of the particular
data concerns or limitations.

HCFA?s fiscal year 1999 and fiscal year 2000 annual performance reports
clearly and consistently identify the results of its goals, targets, and
actual performance with respect to nursing home services. The introduction
of graphics in the fiscal year 2000 report was a positive step. While HCFA?s
reports have a general discussion of data sources, they do not address known
concerns about the validity of data used to measure progress.

HCFA?s current plan addressed a concern we raised about the prior plan- the
lack of measurable targets for two of the three goals. Thus, it established
a baseline and targets for one goal and a fiscal year 2001 target High-
Quality Nursing

Home Services

Page 26 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

for the other goal. However, as discussed in our June 30, 2000 report and
emphasized earlier in this report, we question whether the goals in HCFA?s
2001 performance plan sufficiently address its overall performance in
implementing about 30 nursing home quality- of- care initiatives that HCFA
has had under way since 1998 under the Nursing Home Oversight Improvement
Program. We noted in last year?s report that HCFA?s 2001 performance plan
did not provide information on measuring its performance on the 30
initiatives. HCFA?s fiscal year 2002 performance plan is likewise silent on
measuring such performance. 28

There is little difference between ACF?s fiscal year 1999 and fiscal year
2000 performance reports. Both reports make effective use of tables to list
performance goals, measures, and fiscal year target levels. Changes were
made to the measures themselves, which we characterize below.

While there is little substantive difference between ACF?s fiscal year 2001
and fiscal year 2002 performance plans in terms of strategies, the most
recent plan added an executive summary, which provides a helpful overview of
the document. Moreover, in some instances, the strategies in the 2002 plan
for improving performance and program coordination are more fully developed.
For example, the 2002 plan contains more projects for helping states produce
desired TANF outcomes and strategies to better utilize human capital and
information technology. The plan also discusses technical assistance to, and
partnerships between, ACF?s Housing for the Developmentally Disabled program
and the state Developmental Disabilities Councils. A strength of the fiscal
year 2000 performance report is the inclusion of an updated performance data
chart that was not available for the fiscal year 1999 performance report. In
commenting on a draft of this report, ACF cited the inclusion of workplans
that provide detailed strategies to achieve its targets in the fiscal year
2000 performance report. While not necessarily referred to as a priority
workplan, the fiscal year 1999 performance report lists many of the same
strategies in identical language.

The number and wording of performance measures between the two ACF plans is
similar. However, where target levels in the 2002 plan differed, they were
generally set at higher levels. In many cases, the targets represented
modest increases. Elsewhere, differences represented a

28 GAO/ HEHS- 00- 127R. Self- Sufficiency of Poor

and Disadvantaged Families and Individuals

Page 27 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

significant change over a 1- year period. For example, the Child Care
program?s goal of increasing the number of children served by Child Care and
Development Fund subsidies rose from 2.1 million in fiscal year 2001 to 2.6
million in fiscal year 2002. The HHS Office for Civil Rights? fiscal year
2002 performance plan, however, collapsed several objectives and measures
into a single objective with fewer measures. Some of the new targets
established, however, only provide an indirect indication of compliance and
can actually mask the extent to which compliance is, or is not, achieved. In
commenting on a draft of this report, OCR noted that it would continue to
report tabular information that specifically identifies each of the outputs
that make up the new composite measure. We remain concerned that the tabular
information will be too general to directly assess compliance.

ACF?s fiscal year 2002 plan continues the refocused human capital strategy
it began in prior years. In light of its shrinking workforce and increasing
workload, ACF refocused its human capital measure (manager- to- staff ratio)
in fiscal year 2001 toward the development of a highly skilled, strongly
motivated, and diversified staff. The single measure for this reorientation
is ?each ACF staff member participates in at least one Distance Learning or
other training opportunity directly related to increasing his/ her job
skills.? However, the extent to which this measure captures ACF?s progress
toward meeting its human capital goals remains to be determined. The fiscal
year 2002 plan contains an information technology measure related to ACF?s
continued implementation of an electronic grant- making system. The measure
is to develop and implement a system that will allow ACF to capture and
validate grant information submitted by grantees using the Web. The plan
does not specify particular targets, such as a high percentage of
applications validated by the system, reduced time to process an
application, or grant awards made earlier in the year.

ACF?s fiscal year 2002 plan does not fully respond to concerns we raised in
our HHS GPRA review last year or those identified by the HHS OIG. We
reported last year that ACF did not indicate how it planned to address the
data- reporting lag. Although ACF included a somewhat fuller discussion of
this matter in the fiscal year 2002 plan, we continue to believe that more
specific actions and timelines are warranted. In addition, as discussed in
appendix I, ACF makes little mention of how it intends to respond to several
OIG recommendations and suggestions related to child support enforcement. In
commenting on a draft of this report, ACF said that neither Office of
Management and Budget nor HHS guidance directed them to respond to concerns
expressed by the HHS OIG or GAO. However,

Page 28 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

our discussions with HHS officials responsible for coordinating the
Department?s comments on our report suggest that HHS does take our analysis
of its GPRA reports into account and attempts to correct shortcomings we
have identified.

For each HHS component reviewed with respect to infectious disease
prevention, the fiscal year 1999 and fiscal year 2000 performance reports
are similar. The agencies employed the same general format to summarize
goals, targets, and actual performance, and in referring to an additional
source of information (typically the budget justifications). This summary is
generally accompanied by informative narrative that expands on the goal and
related performance.

For each of the relevant HHS components, the fiscal year 2001 and fiscal
year 2002 performance plans are similar in content and organization.
However, in both plans, the strategies and resources used to achieve goals
were not always adequately addressed. Some components made revisions to or
increased the number of their infectious disease prevention goals, and each
provided a general discussion of plan changes. When goals or targets were
revised, they generally provided rationales for these changes. None of the
changes substantially strengthened or weakened the product. CDC, however,
improved its fiscal year 2002 performance plan by making extensive revisions
that more effectively communicated and linked its goals, measures, and
targets with the strategies for achieving them. CDC also addressed most of
the data quality concerns expressed by us and the Congress. As noted
earlier, HRSA indicated that the electronic submission of data addresses
reliability and validity concerns we had raised previously. Despite these
specific data- quality improvements, the components do not always discuss
why particular goals may be poorly measured.

SAMHSA?s fiscal year 2000 performance report demonstrates little progress in
overcoming a major weakness we noted in its previous report. As in last
year?s report, it continues to rely on states to validate the information
they reported in block grant applications for their goal related to the 20
percent Substance Abuse Prevention and Treatment Block Grant Prevention Set
Aside program. While the current report notes that states must certify the
accuracy of block grant data, SAMHSA does not describe states? procedures
for this or how SAMHSA project officers verify the states? certifications.
Another continuing limitation is SAMHSA?s failure to discuss the findings
and recommendations of evaluations or how results Prevention of Infectious

Diseases, Including Vaccine- Preventable Diseases

Use of Illegal Drugs

Page 29 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

were used to assess performance. Both we and the HHS OIG have recommended
that SAMHSA perform such evaluations.

In its fiscal year 2002 plan, SAMHSA continued its practice of highlighting
changes and improvements over its prior- year plan. Thus, SAMHSA has adopted
a more comprehensive approach to performance management by reporting on
performance goals for all significant programs. Two key performance goals
were added to its 2002 plan to increase SAMHSA?s ability to assess Substance
Abuse and Treatment Prevention Block Grant customer satisfaction. SAMHSA is
also working on initiatives to enhance the performance reporting process.
These initiatives include establishing a requirement for states to report
performance data in SAMHSA grant funding applications, and developing
analysis plans for GPRA assessments to better manage programs and measure
their effectiveness. However, the 2002 plan does not discuss SAMHSA?s
efforts to verify the quality of the performance data reported by states- an
observation that we made about the prior- year plan. We did find that when
goals were added or modified for clarity, SAMHSA described the reasons and
the results to be achieved from the change. In addition, when goals were
dropped or modified, the 2002 plan stated that either the goal had been
completed or revisions had been made to better focus the goal on outcomes.

FDA?s performance reports have been consistently well organized, clear and
concise. However, several goals in both the fiscal year 1999 and fiscal year
2000 performance reports lack adequate descriptions of the benefits to
public safety and health attained by FDA?s performance. For example, both
the Human Drugs and the Medical Device programs established goals of
ensuring that inspections of domestic medical drug and device manufacturing
facilities resulted in timely correction of serious deficiencies in
accordance with FDA requirements. However, neither program in either report
elaborated on the expected benefits beyond reporting attainment of the
statistical goal. In contrast, FDA?s description of the mammography facility
performance goal explained that inspections were expected to enhance the
quality of images leading to the more accurate and timely detection of
breast cancer.

In its most recent plan, FDA has continued to improve its presentation. FDA
made strong use of graphics interspersed with narrative to present its
strategies and also included a helpful program overview. It also discussed
its strategies for accomplishing goals and the consequences of not achieving
them- overcoming a weakness we noted in the fiscal year 2001 plan. FDA?s
fiscal year 2002 performance plan added new goals and Access to Safe and

Effective Medical Drugs and Devices

Page 30 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

slightly modified or reiterated others. New goals included increased
inspections of medical device studies, which resulted from a heightened
concern about clinical abuses; stepped up foreign inspections and expanded
import coverage of all medical products to improve the safety of imported
products; and enhanced surveillance of FDA- regulated products to prevent
deaths and injuries related to the use of medical products. However, these
new goals did not include baselines or concrete targets against which to
measure progress. As noted earlier, FDA did not always address concerns we
raised last year about the validity of performance information.

We have identified two governmentwide high- risk areas: strategic human
capital management and information security. Regarding human capital, HHS
does not have departmental performance goals related to this highrisk area.
Although it is engaged in workforce planning, HHS only briefly outlines this
effort. Several HHS components, however, have such goals and measures in
their plans, and some cite progress. Similarly, HHS has no departmental
goals related to information security, but HCFA has established an
aggressive program to address problems in this area.

In addition, we identified five other major management challenges facing
HHS. The performance reports and plans of HHS components included goals and
measures directly related to four of these challenges. We found that HCFA is
making some progress in addressing fraud in Medicare and Medicaid and that,
while its goals are very narrow, it continues to make progress toward
improving nursing home quality. With regard to the outcome of promoting
self- sufficiency among the poor, we could not fully assess ACF?s progress
because most goals lacked the necessary fiscal year 2000 performance data.
For those goals with data, results were mixed. Only FDA?s outcome of
ensuring prompt access to safe and effective medical drugs and devices
demonstrated significant progress. For the fifth challenge- ensuring a well-
designed and administered Medicare program- HCFA has a workforce planning
goal to reduce the gap between the current and the targeted levels of skills
and is using outside assistance to develop a comprehensive database
documenting its employee positions, skills, and functions. On its own, HCFA
cannot address other aspects of the human capital challenges we identified.
In summary, we found that the HHS reports discussed making at least some
progress for all seven major management challenges (including the two high-
risk areas). Of the seven major management challenges identified by GAO,
HHS? performance plans had (1) goals and measures directly related to six of
the challenges, and (2) goals and measures that indirectly related to one of
the challenges. HHS? Efforts to

Address Its Major Management Challenges Identified by GAO

Page 31 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Appendix I provides detailed information on how HHS addressed these
challenges and high- risk areas as identified by us and the Department?s
OIG.

It is difficult to fully assess HHS? progress in fiscal year 2000 toward
achieving the outcomes we reviewed because lags in reporting performance
data are common for many of its components such as ACF, CDC, SAMHSA, and
FDA. In some cases, the delays are associated with the need to obtain
performance data from states and local organizations. Some HHS components
are working to improve the timeliness of data submitted by others and, in
some instances, have reported trend data to show that progress is being
made. For example, both ACF and CDC supplied fiscal year 1999 performance
data in their current performance reports- data that were not available
until this year. It is likely that ACF?s and CDC?s fiscal year 2001
performance reports will include fiscal year 2000 performance data that were
not available this year. While it may not always be realistic to expect the
availability of complete data at the same time annual performance reports
and plans are issued, trends will become apparent as the number of
performance reports grows with each passing year.

The six HHS outcomes that were used as the basis for our review were
identified by the Ranking Minority Member of the Senate Committee on
Governmental Affairs as important mission areas and do not reflect the
outcomes for all of HHS? programs or activities. Given the outcomes selected
by the Committee and the management challenges we examined, our review
focused on about 150 goals discussed in the reports and plans of 10
components- Administration on Aging, ACF, CDC, FDA, HCFA, HRSA, IHS, NIH,
OCR, and SAMHSA. 29 We also reviewed the overall HHS summary, which
highlights the reports of its operating components. As agreed, our
evaluation was generally based on the requirements of GPRA, the Reports
Consolidation Act of 2000, guidance to agencies from the Office of
Management and Budget (Circular A- 11, Part 2) for developing performance
plans and reports, and previous reports and evaluations by us and others. We
also relied on our knowledge of HHS? operations and programs, our
identification of best practices concerning performance planning and
reporting, and our observations on HHS? other GPRA- related

29 HHS? 17 operating components and staff offices have over 950 annual
performance goals. Conclusions

Scope and Methodology

Page 32 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

efforts. We discussed our review with HHS officials, including the HHS OIG.
We identified the major management challenges confronting HHS, including the
governmentwide high- risk areas of strategic human capital management and
information security, in our January 2001 performance and accountability
series and high- risk update. The HHS OIG identified major management
challenges confronting HHS in a December 2000 letter to the Congress. We did
not independently verify the information contained in the performance
reports and plans, although we did draw from our other work in assessing the
validity, reliability, and timeliness of HHS? performance data. We conducted
our review from April 2001 through June 2001 in accordance with generally
accepted government auditing standards.

In commenting on a draft of this report, HHS said it found our report ?fair,

thorough, and comprehensive.? We have addressed specific comments that HHS
suggested would increase the report?s accuracy as well as other technical
comments in the corresponding sections of the report. HHS? comments are
included as appendix II.

As arranged with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days after
the date of this letter. At that time, we will send copies to appropriate
congressional committees; the Secretary of Health and Human Services; and
the Director, Office of Management and Budget. Copies will also be made
available on request.

If you or your staff have any questions, please call me at (312) 220- 7600.
Key contributors to this report were John Brennan, Bonnie Brown, Kim Brooks,
Brett Fallavollita, Darryl Joyce, Don Keller, Clarita Mrena, Walter Ochinko,
and William Thompson.

Sincerely yours, Leslie G. Aronovitz Director, Health Care- Program

Administration and Integrity Issues Agency Comments

Appendix I: Observations on HHS? Efforts to Address Its Major Management
Challenges

Page 33 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

The following table identifies the major management challenges confronting
HHS, which include the governmentwide high- risk areas of strategic human
capital management and information security. The first column lists the
challenges that we and/ or the HHS OIG have identified. The second column
discusses what progress, as identified in its fiscal year 2000 performance
reports, HHS components have made in resolving the challenges. The third
column discusses the extent to which the fiscal year 2002 performance plans
of the HHS components include performance goals and measures to address the
challenges that we and the HHS OIG identified. We found that the performance
reports of HHS? components discussed the progress in resolving some
challenges, but did not discuss progress in resolving the following: abuses
in Medicaid payment systems; Medicare equipment and supplies; Medicare
payments for mental health services; Medicare prescription drugs; oversight
of prospective payment systems; and child support enforcement. Of HHS? 19
major management challenges, its performance plans had (1) goals and
measures that were directly related to 10 of the challenges; (2) goals and
measures that were indirectly applicable to 2 of the challenges; and (3) no
goals, measures, or strategies to address 7 of the challenges.

Table 1: Major Management Challenges Major management challenge

Progress in resolving major management challenge as discussed in the fiscal
year 2000 performance report Applicable goals and measures in the

fiscal year 2002 performance plan GAO- designated governmentwide high- risk
areas

Strategic Human Capital Management:

GAO has identified shortcomings at multiple agencies involving key elements
of modern human capital management, including strategic human capital
planning and organizational alignment; leadership continuity and succession
planning; acquiring and developing staffs whose size, skills, and deployment
meet agency needs; and creating results- oriented organizational cultures.

HHS reports that it is facing a ?human capital crisis.? Within the next 5
years, about 27 percent of its current workforce will be eligible to retire.
Although HHS says that it is engaged in workforce planning, it only briefly
outlines this effort. It asserts that it will develop a plan to meet future
departmental workforce requirements through a comparison of current employee
skills/ experience and projected needs.

There were some examples of progress. CDC met its fiscal year 2000 goal of
decreasing the time to refer candidates for vacancies by 25 percent, and
HCFA is making progress in its workforce planning effort.

HHS does not have departmental performance goals related to this challenge.
However, some of its components have such goals and measures in their fiscal
year 2002 plans. In general, HHS could do a better job demonstrating how it
is using human capital strategies to improve performance. Selected examples
follow:

Administration on Aging (AoA): AoA has a developmental goal to base a high
percentage of its hires on a formal AoA workforce plan. HHS characterized
AoA?s workforce planning effort as ?significant,? but AoA?s fiscal year 2002
performance plan provides no further details.

ACF: As part of an overall strategic goal to build a results- oriented
organization, ACF established an objective of developing and retaining a
highly skilled, strongly

Appendix I: Observations on HHS? Efforts to Address Its Major Management
Challenges

Appendix I: Observations on HHS? Efforts to Address Its Major Management
Challenges

Page 34 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Major management challenge Progress in resolving major

management challenge as discussed in the fiscal year 2000 performance report
Applicable goals and measures in the

fiscal year 2002 performance plan

motivated staff. ACF reported that it will develop and begin implementing an
action plan to address any identified gaps in the staffing needed to
complete core workloads or in employees? competencies based on workforce
planning started in fiscal year 2001.

CDC: CDC regards the recruitment and retention of highly- qualified staff as
a top priority. One of its program support goals is to decrease the time it
takes to refer candidates for vacancies and the time entailed in classifying
positions and to maintain this referral reduction.

HCFA: See discussion below under first GAO management challenge.

SAMHSA: SAMHSA intends to complete a workforce plan in August 2001 that
includes recommendations on ensuring that staffing levels are sufficient to
manage program growth, maintain a well- trained workforce, and provide a
high- quality work life. SAMHSA also plans to benchmark government and
nongovernment best practice human capital management processes and
incorporate them in its workforce plan.

Information Security: Our January 2001 high- risk update noted that the
agencies? and governmentwide efforts to strengthen information security have
gained momentum and expanded. Nevertheless, recent audits continue to show
federal computer systems are riddled with weaknesses that make them highly
vulnerable to computer- based attacks and place a broad range of critical
operations and assets at risk of fraud, misuse, and disruption.

HHS reports on progress made by HCFA in addressing information security
weaknesses. HCFA established an aggressive program involving updated
information security policies and increased oversight with specific target
expectations and milestone dates for each of its information security
performance goals. For example, HCFA set out to correct the two outstanding
material weaknesses from fiscal year 1997. HCFA corrected only one of the
two material weaknesses by the targeted date- fiscal year 2000.

HHS does not have departmental performance goals related to this challenge.
However, HCFA has such goals and measures in its fiscal year 2002 plan.

HCFA established a performance goal to improve its information systems
security policies and practices enterprisewide. Specific tasks under this
goal included:

eliminating all material weaknesses

increasing the percentage of employees receiving security training

increasing the proportion of Medicare contractor sites receiving security
reviews

evaluating Medicare contractors? security profiles against a baseline

applying a baseline to HCFA?s business partners

These tasks are scheduled for incremental

Appendix I: Observations on HHS? Efforts to Address Its Major Management
Challenges

Page 35 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Major management challenge Progress in resolving major

management challenge as discussed in the fiscal year 2000 performance report
Applicable goals and measures in the

fiscal year 2002 performance plan

completion. For example, the elimination of all material weaknesses is
scheduled to be achieved in fiscal year 2002 but HCFA does not expect to
complete the evaluation process for all Medicare contractors for 3 to 4
years.

GAO- designated major management challenges

Provide current and future generations with a well- designed and
administered Medicare program: GAO has identified a number of human capital
challenges facing HCFA. First, despite Medicare?s size and complexity, there
is no official whose sole responsibility is to run that program. In addition
to Medicare, HCFA?s Administrator and top- level management have oversight
and administrative responsibilities for other major health- related programs
and initiatives such as Medicaid, the State Children?s Health Insurance
Program, and nursing homes. Second, frequent changes in leadership have
inhibited the implementation of long- term Medicare initiatives and the
pursuit of a consistent management strategy. Third, HCFA?s staff lack the
experience and training to deal with some of the complex new
responsibilities mandated by the Balanced Budget Act of 1997. Finally, with
one- third of its staff eligible to retire within the next 5 years, HCFA
faces the loss of valuable institutional knowledge.

HCFA has embarked on the development of a workforce planning system to help
managers make strategic plans for staffing and human resources development.
To assess its needs systematically, HCFA?s workforce planning process has
four phases to identify current and future competencies needed to carry out
its mission and analyze any gaps. HCFA initiated this process using outside
assistance to develop a comprehensive database documenting its employee
positions, skills, and functions.

In its 2002 performance plan, HCFA established a new performance goal
intended to reduce the gap between its current and targeted levels of skills
and knowledge. HCFA anticipates having data in fiscal year 2001 to formally
measure skill and knowledge gaps, which will then be prioritized on the
basis of their breadth, depth, and criticality for accomplishing HCFA
strategic goals. The gaps will be closed by strategic activities to recruit,
develop, and redeploy employees. On its own, HCFA cannot address several of
the human capital challenges we identified, such as the scope of the tasks
facing HCFA leadership or frequent leadership changes. Elements of recent
Medicare reform proposals and alternative models drawn from other federal
agencies suggest ways to address focus, leadership, and capacity issues.
Options proposed include creating an entity that would administer Medicare
without any non- Medicare responsibilities; establishing tenure for the
program?s administrator that, at a minimum, would overlap presidential
terms; and granting the entity administering Medicare greater operational
flexibility.

Improve oversight of nursing homes so that residents receive quality care
This management challenge is very similar

to an HHS outcome that is discussed in the letter portion of this report.

This management challenge is very similar to an HHS outcome that is
discussed in the letter portion of this report.

Enhance the economic independence and well- being of children and families
This management challenge is very similar

to an HHS outcome that is discussed in the letter portion of this report.

This management challenge is very similar to an HHS outcome that is
discussed in the letter portion of this report.

Ensure the safety and efficacy of medical products This management challenge
is very similar

to an HHS outcome that is discussed in the letter portion of this report.

This management challenge is very similar to an HHS outcome that is
discussed in the letter portion of this report.

GAO- and HHS OIG- designated major management challenges

Better safeguard the integrity of the Medicare program

(Oversight of prospective payment system implementation: Both GAO and the
HHS

This management challenge is very similar to an HHS outcome that is
discussed in the letter portion of this report.

HCFA reports that it has successfully implemented several new PPSs. However,

This management challenge is very similar to an HHS outcome that is
discussed in the letter portion of this report.

HCFA?s fiscal year 2002 plan does not contain goals and measures to address

Appendix I: Observations on HHS? Efforts to Address Its Major Management
Challenges

Page 36 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Major management challenge Progress in resolving major

management challenge as discussed in the fiscal year 2000 performance report
Applicable goals and measures in the

fiscal year 2002 performance plan

OIG have identified significant risk of payment exploitation in the new
prospective payment systems (PPS) mandated by the Balanced Budget Act of
1997. Though PPSs are intended to encourage the efficient provision of
services, they also give providers a new opportunity to boost net revenues
inappropriately by skimping on services and compromising the patient?s
quality of care.)

(Medicare managed care: Both GAO and the HHS OIG have reported that
Medicare?s managed care component raises program integrity challenges
involving excessive payments for enrollees.)

HCFA does not address progress in responding to the OIG?s and GAO?s concerns
that these payment systems are subject to exploitation.

HCFA met its fiscal year 2000 goal to begin making risk- adjusted payments
to managed care plans- a goal that was mandated by the Balanced Budget Act
of 1997. Risk- adjusted payments should help to reduce overpayments to
managed care plans that attract healthier than average beneficiaries.

oversight of the PPSs that have been implemented even though HCFA plans to
award a contract for such oversight later this year.

HCFA has a continuing goal to complete the implementation of its risk-
adjustment method. This phased implementation began in January 2000 and is
not scheduled to be completed until after 2004.

HHS OIG- designated major management challenges

Medicare payment error rate This OIG management challenge is discussed under
the ?fraud, waste, and error? outcome in the letter portion of this report.

This OIG management challenge is discussed under the ?fraud, waste, and
error? outcome in the letter portion of this report.

Medicare contractors This OIG management challenge is discussed under the
?fraud, waste, and error? outcome in the letter portion of this report.

This OIG management challenge is discussed under the ?fraud, waste, and
error? outcome in the letter portion of this report.

Home health This OIG management challenge is discussed under the ?fraud,
waste, and error? outcome in the letter portion of this report.

This OIG management challenge is discussed under the ?fraud, waste, and
error? outcome in the letter portion of this report.

Abuses in Medicaid Payment Systems:

The OIG reports that several states abused the Medicaid payment system by
making enhanced payments to city- and countyowned providers or hospitals
that were not based on the actual costs of providing services to Medicaid
beneficiaries. Although the practice was not illegal, states enhanced
payments to increase the amount of the federal match for Medicaid
expenditures. In addition, the enhanced payments were not retained by the
facilities and used to provide services to Medicaid beneficiaries served by
them. Instead, billions of federal Medicaid dollars were returned by the
providers/ hospitals to the states through intergovernmental transfers.

HCFA?s performance report does not discuss progress made in resolving this
issue.

Changes in regulations have been implemented related to limiting the amount
of federal Medicaid dollars available to states as enhanced payments.
However, the plan does not include a discussion of these matters.

No goals exist in HCFA?s performance plan related to this issue.

Medicare equipment and supplies: The HHS OIG believes that Medicare HCFA?s
performance report does not

discuss progress made in resolving this HCFA?s performance plan has no goals
related to this management challenge.

Appendix I: Observations on HHS? Efforts to Address Its Major Management
Challenges

Page 37 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Major management challenge Progress in resolving major

management challenge as discussed in the fiscal year 2000 performance report
Applicable goals and measures in the

fiscal year 2002 performance plan

excessively reimburses for some items and that programmatic reforms are
warranted. It also believes that structural reforms, such as improving
billing practices for orthotics, revising coding guidelines for therapeutic
footwear, and charging an application fee for suppliers should be made. It
also recommends improved medical review in such areas as oxygen therapy.

challenge.

Medicare payment for mental health services: Medicare payments for mental
health services in a variety of settings- including payments to community
mental health centers for partial hospitalization services- have been an
ongoing concern for the HHS OIG. Although partial hospitalization consists
of an intensive program of outpatient services for acutely ill beneficiaries
in order to prevent inpatient hospitalization, OIG and HCFA reviews have
found that Medicare was paying for services to beneficiaries with no history
of mental illness and for beneficiaries who suffered from conditions that
would preclude them from benefiting from the program.

HCFA?s performance report does not discuss progress in resolving this
challenge.

HCFA?s fiscal year 2002 plan does not contain goals and measures for this
issue. However, HCFA indicates that a fiscal year 2001 goal to implement the
Comprehensive Plan for Program Integrity includes an initiative to reduce
the percentage of errors in community mental health center claims. It
reports that this goal will be completed in fiscal year 2001.

Nursing facilities See our discussion of aspects of the HHS OIG?s management
challenge under the

?High- Quality Nursing Home Services? section in the letter portion of this
report. Challenges related to the Skilled Nursing Facility PPS are addressed
earlier in this table under the GAO management challenge of ?better
safeguard the integrity of the Medicare program.?

See our discussion of aspects of the HHS OIG?s management challenge under
the

?High- Quality Nursing Home Services? section in the letter portion of this
report. Challenges related to the Skilled Nursing Facility PPS are addressed
earlier in this table under the GAO management challenge of ?better
safeguard the integrity of the Medicare program.?

Medicare prescription drugs: Medicare coverage for outpatient prescription
drugs is limited primarily to drugs used in dialysis, organ transplantation,
and cancer treatment. The OIG has reported that Medicare pays too much for
prescription drugs and has concluded that Medicare?s payment methodology is
fundamentally flawed.

HCFA?s report does not discuss progress in resolving this challenge. No
goals exist in HCFA?s plan on this

management challenge.

Medicare managed care: Medicare beneficiaries have the option of enrolling
in managed care plans, which contract with HCFA to furnish all medically
necessary services covered under the Medicare program. OIG concerns in this
area center on Medicare payment rates, on quality- of In fiscal year 2000,
HCFA established a

goal to improve the effectiveness of dissemination of Medicare information
to beneficiaries through the National Medicare Education Program so that by
fiscal year 2004, 57 percent of beneficiaries will know that most people

HCFA?s fiscal year 2002 plan reports that HCFA is on track toward meeting
the goal of improving the effectiveness of dissemination of Medicare
information to beneficiaries by fiscal year 2004. In addition, the plan has
a goal under development to improve beneficiaries?

Appendix I: Observations on HHS? Efforts to Address Its Major Management
Challenges

Page 38 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Major management challenge Progress in resolving major

management challenge as discussed in the fiscal year 2000 performance report
Applicable goals and measures in the

fiscal year 2002 performance plan

care issues, and on how well informed Medicare beneficiaries are of the
choices available to them.

covered by Medicare can select from among different health plan options.
HCFA reports limited progress in meeting this goal because it is currently
collecting and monitoring the Medicare Current Beneficiary Survey data for
final reporting in fiscal year 2004.

understanding of Medicare?s basic features.

The fiscal year 2002 plan does not contain new goals to address concerns
over other aspects of this challenge raised by the OIG and GAO.

Oversight of prospective payment system implementation See previous section
under GAO

management challenge of ?better

safeguard the integrity of the Medicare program.?

See previous section under GAO management challenge of ?better

safeguard the integrity of the Medicare program.?

Child support enforcement: The OIG has made several recommendations and
suggestions aimed at improving TANF and Medicaid- only client cooperation
with child support enforcement. The OIG has also recommended the expansion
of nonhospital settings in helping establish paternity. Also, the OIG has
made several recommendations to improve the Child Support Enforcement
Program?s annual report to the Congress.

ACF made little mention of addressing these OIG recommendations and
suggestions in its fiscal year 2000 performance report. ACF?s report
mentioned technical assistance, better collaboration, and state staff
training, but these efforts were not tied to the HHS OIG specific concerns.
ACF had a general statement about ?partnering with birth record agencies,
pre- natal clinics and other entities? as an early intervention in
establishing paternity.

ACF?s fiscal year 2002 performance plan did not list goals and measures
directly related to the OIG recommendations and suggestions. However, to the
extent that the OIG?s recommendations are implemented, they would help ACF
achieve the three goals associated with the Child Support Enforcement
Program: (1) children have parentage established, (2) children have
financial and medical support orders, and (3) children receive financial and
medical support from both parents.

Protection of critical infrastructure: As part of an administration
initiative, the HHS OIG is overseeing HHS? efforts to improve critical
infrastructure protection.

HHS reported that it has adopted an organizationwide approach that
centralizes and standardizes controls over its electronic data processing
environment. HHS also plans to work with its components to enhance
interoperability within the department, reduce duplication of equipment and
services, and provide for secure systems during emergencies. Aside from this
general outline of its approach, HHS does not provide specific examples of
progress.

HHS has no departmental goals involving protection of critical
infrastructure. HHS noted that the performance plans of its components
contain goals that address aspects of critical infrastructure protection and
stated that HHS plans to develop additional goals that will address the
issue more directly.

Appendix II: Comments From the Department of Health and Human Services

Page 39 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Appendix II: Comments From the Department of Health and Human Services

Appendix II: Comments From the Department of Health and Human Services

Page 40 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Appendix II: Comments From the Department of Health and Human Services

Page 41 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Appendix II: Comments From the Department of Health and Human Services

Page 42 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Appendix II: Comments From the Department of Health and Human Services

Page 43 GAO- 01- 748 HHS' Status of Achieving Key Outcomes

Appendix II: Comments From the Department of Health and Human Services

Page 44 GAO- 01- 748 HHS' Status of Achieving Key Outcomes (290049)

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