Health, Education, Employment, Social Security, Welfare, and Veterans
Reports (Letter Report, 09/01/95, GAO/HEHS-95-261W).

This booklet lists GAO documents on government programs related to
health, education, employment, social security, welfare, and veterans
issues, which are primarily run by the Departments of Health and Human
Services, Labor, Education, and Veterans Affairs. One section identifies
reports and testimony issued during the past months and summarizes key
products. Another section lists all documents published the past year,
organized chronologically by subject. Order forms are included.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-95-261W
     TITLE:  Health, Education, Employment, Social Security, Welfare, 
             and Veterans Reports
      DATE:  09/01/95
   SUBJECT:  Health care services
             Educational programs
             Welfare benefits
             Veterans benefits
             Medicare programs
             Aid for training or employment
             Retirement pensions
             Medicaid programs
             Social security benefits
IDENTIFIER:  Bibliographies
             
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Cover
================================================================ COVER


Health, Education, and Human
Services Division Reports

September 1995

HEALTH
EDUCATION
EMPLOYMENT
SOCIAL SECURITY
WELFARE
VETERANS

GAO/HEHS-95-261W



Abbreviations
=============================================================== ABBREV

  COLA - Cost of living allowance
  DC - District of Columbia
  DOD - Department of Defense
  GAO - General Accounting Office
  HCFA - Health Care Financing Administration
  HEHS - Health, Education, and Human Services Division, GAO
  HHS - Department of Health and Human Services
  HMO - health maintenance organization
  HRD - Human Resources Division, GAO
  ORI - Office of Research Integrity, HHS
  PSDA - Patient Self-Determination Act
  SSA - Social Security Administration
  SSI - Supplemental Security Income
  TRICARE - DOD nationwide managed health care program
  VA - Department of Veterans Affairs
  WAIS - Wide Area Information Server
  WWW - World Wide Web

PREFACE
============================================================ Chapter 0

The General Accounting Office (GAO), an arm of the Congress, was
established to independently audit government agencies.  GAO's
Health, Education, and Human Services (HEHS) Division reviews the
government's health, education, employment, social security,
disability, welfare, and veterans programs administered in the
Departments of Health and Human Services, Labor, Education, Veterans
Affairs, and some other agencies.

This file contains selected key reports and testimonies issued by GAO
on these programs in August 1995.  These summaries were taken from
Health, Education, and Human Services Division Reports, a monthly
booklet which contains the following information:

Most Recent GAO Products:  This section identifies reports and
testimonies issued during the past month and provides summaries for
selected key products. 

Comprehensive 1-Year Listings:  This section lists all products
published in the last year, organized chronologically by subject. 
When appropriate, products may be included in more than one subject
area. 

You may obtain single copies of the products free of charge, by
telephoning your request to (202) 512-6000 or faxing it to (301)
258-4066.  Additional ordering details, as well as instructions for
getting on our mailing list, appear at the end of this file. 

You may access the Most Recent GAO Products section of this booklet
on Internet.  Instructions appear on the last two pages of this
booklet.





Janet L.  Shikles
Assistant Comptroller General


MOST RECENT GAO PRODUCTS
(AUGUST 1995)
============================================================ Chapter 1


   HEALTH
---------------------------------------------------------- Chapter 1:1


      SELECTED SUMMARIES
-------------------------------------------------------- Chapter 1:1.1

Patient Self-Determination Act:  Providers Offer Information on
Advance Directives but Effectiveness Uncertain (Report, 8/28/95,
GAO/HEHS-95-135). 

Health care institutions and the Department of Health and Human
Services (HHS) generally appear to comply with most Patient
Self-Determination Act (PSDA) requirements.  Surveys, facility
inspections, and industry officials indicated that nearly all
providers inform patients about their right to have an advance
directive, but fewer consistently document in the medical record
whether a patient has one.  HHS has incorporated PSDA provisions into
Medicare and Medicaid provider requirements, expanded the Medicare
handbook, and conducted a limited public education campaign. 
However, the agency has not mailed a notification of advance
directives to Social Security recipients--a specific requirement of
the act.  GAO found that advance directives have been advocated more
than they have been used.  The provider groups GAO spoke with
generally support advance directives.  Yet, advance directives may
not always be implemented as patients intend.  A variety of factors
affects whether an advance directive actually controls end-of-life
decisions, including the availability or specificity of a living
will, family wishes, and legal issues. 

Medigap Insurance:  Insurers' Compliance With Federal Minimum Loss
Ratio Standards, 1988-93 (Report, 8/23/95, GAO/HEHS-95-151). 

The Medigap market grew steadily over the 1988-93 period, from $7.3
billion to $12.1 billion.  Medigap insurers' aggregate loss ratios
were relatively stable during the first 4 years of that period.  Over
the next 2 years, however, these ratios decreased about 10 percentage
points, to an aggregate 75 percent for individual policies and 85
percent for group policies.  In 1991, 19 percent of Medigap policies
failed to meet loss ratio standards; this increased to 38 percent by
1993.  The premium dollars spent on such policies increased from $320
million in 1991 to $1.2 billion in 1993.  If insurers had been
required to give refunds or credits on substandard policies, as they
will in the future, policyholders would have been due about $125
million over 1992 and 1993. 


Medicare:  Excessive Payments for Medical Supplies Continue Despite
Improvements (Report, 8/8/95, GAO/HEHS-95-171). 

Unwarranted Medicare expenditures for medical supplies persist for
several reasons.  First, many Medicare contractors still lack
internal controls that would reliably identify suspicious medical
supply claims before payment.  Second, Medicare payment rates for
surgical dressings are high compared with wholesale and many retail
prices.  The Health Care Financing Administration (HCFA) and its
contractors know about these problems and have tried to address some
of them.  These efforts have provided more and better information,
which suggests that inadequate controls are causing Medicare to lose
hundreds of millions of dollars.  HCFA could curtail these losses by
establishing procedures to (1) identify what Medicare is being asked
to pay for; (2) prevent duplicate payments; and (3) identify
high-dollar, high-volume claims that should be reviewed before
payment.  Further, HCFA needs the legislative authority to set
payments at rates more favorable to large-volume purchasers. 

Medicare:  Increased HMO Oversight Could Improve Quality and Access
to Care (Report, 8/3/95, GAO/HEHS-95-155).  Testimony on same topic
(8/3/95, GAO/T-HEHS-95- 229). 

Although HCFA has instituted several promising improvements, its
process for monitoring and enforcing Medicare health maintenance
organization (HMO) operating standards continues to suffer from three
significant limitations:  (1) quality assurance reviews are not
comprehensive, (2) enforcement actions are weak, and (3) the appeal
process is slow.  Increasingly, sponsors of employee health plans are
requiring that HMOs undergo accreditation reviews to obtain contracts
with their plans.  Moreover, the leading HMO accreditation agency
publicizes results of its reviews.  Some large employers also require
information about the care provided to gauge an HMO's overall
performance when making contract decisions.  HCFA's current
regulatory approach to ensuring good HMO performance lags behind
these latest private-sector practices. 

Health Research Misconduct:  HHS' Handling of Cases Is Appropriate,
but Timeliness Remains a Concern (Report, 8/3/95, GAO/HEHS-95-134). 

The HHS Office of Research Integrity (ORI) has made progress in its
handling of misconduct cases since its establishment in May 1992. 
However, it still faces a substantial case backlog and lengthy delays
in completing its work.  By November 1992, ORI had developed and
implemented procedures for handling misconduct cases.  GAO was unable
to fully assess how well ORI investigators followed appropriate
procedures in all misconduct cases.  Despite implementing new
procedures, ORI continues to experience delays in closing cases.  ORI
currently has 43 employees, down from 50 in 1994.  Only 11 of ORI's
workforce, however, are directly involved in handling misconduct
cases.  In response to our findings and an HHS Office of the
Inspector General report, ORI has initiated a number of actions to
improve productivity and plans to refine its planning processes
during the next fiscal year. 


      OTHER HEALTH PRODUCTS
-------------------------------------------------------- Chapter 1:1.2

Medicare Competitive Bidding (Letter, 8/11/95, GAO/HEHS-95-238R). 

Planned Parenthood (Letter, 8/9/95, GAO/HEHS-95-216R). 


   EDUCATION
---------------------------------------------------------- Chapter 1:2


      SELECTED SUMMARIES
-------------------------------------------------------- Chapter 1:2.1

National Service Programs:  AmericCorps*USA--Early Program Resource
and Benefit Information (Report, 8/29/95, GAO/HEHS-95-222). 

For the program year 1994-95, GAO's estimate of the Corporation for
National and Community Service resources available per participant
was about $17,600, slightly less than the Corporation's March 24,
1995, estimate.  Using GAO's methodology, total resources available
for AmeriCorps*USA programs included more than the Corporation's
appropriations.  Over one-third of the financial resources available
for AmericCorps*USA grantees' programs came from sources outside the
Corporation, mostly from other federal agencies and state and local
governments.  Total resources available per AmericCorps*USA
participant averaged $26,654, of which about $17,600 came from the
Corporation, $3,200 from non-Corporation federal sources, and $4,000
from state and local governments.  The remaining amount, roughly
$1,800, came from the private sector.  Total resources available to
AmeriCorps*USA grantees' programs equaled about $16 per service hour. 
Resources available per participant were lower for programs run by
nonfederal organizations than those funded by federal agencies.  In
terms of benefits, GAO's review of activities at the seven program
sites visited indicated that a variety of results have been achieved
that support AmericCorps*USA's goals. 

College Savings:  Information on State Tuition Prepayment Programs
(Report, 8/3/95, GAO/HEHS-95-131). 

Tuition prepayment programs represent one approach that some states
have adopted to encourage families to save for their children's
college educations.  Although the seven programs GAO studied all
operated similarly, they also have many unique features that
distinguish them from one another.  Most participants in state
tuition prepayment programs come from middle and upper income
families; lower income families are underrepresented.  Four major
issues concerning these programs are (1) the potential effect they
have on students' educational choices; (2) their appeal to mostly
middle- and upper income families, and the possibility that such
families receive subsidies through participation; (3) their value as
an investment for purchasers; and (4) the degree of risk they pose
for states.  Questions remain unresolved about the potential tax
liability of purchasers, beneficiaries, and the programs themselves. 


      OTHER EDUCATION PRODUCTS
-------------------------------------------------------- Chapter 1:2.2

Direct Student Loans (Letter, 8/25/95, GAO/HEHS-95-225R). 


   SOCIAL SECURITY, DISABILITY,
   AND WELFARE
---------------------------------------------------------- Chapter 1:3


      SELECTED SUMMARIES
-------------------------------------------------------- Chapter 1:3.1

Supplemental Security Income:  Disability Program Vulnerable to
Applicant Fraud When Middlemen Are Used (Report, 8/31/95,
GAO/HEHS-95-116). 

Although some ineligible non-English-speaking applicants have
obtained Supplemental Security Income (SSI) benefits illegally by
using middlemen, the actual number of people who have done so is
unknown.  SSI's vulnerability to fraudulent applications involving
middlemen is the product of a combination of factors.  First, Social
Security Administration (SSA) management practices and bilingual
staff shortages enable applicants to use middlemen.  Furthermore,
SSA's vulnerability to fraud when middlemen are involved has been
compounded by SSA's limited monitoring of middlemen, the HHS Office
of Inspector General's limited funds for investigations, and the lack
of coordination between the efforts of SSA and state Medicaid
agencies.  Finally, SSA needs a more comprehensive, programwide
strategy for keeping ineligible applicants from ever being accepted
on the SSI rolls.  The Congress, SSA, and several states have
initiated efforts to prevent or detect fraudulent SSI claims
involving middlemen. 


      OTHER SOCIAL SECURITY,
      DISABILITY, AND WELFARE
      PRODUCTS
-------------------------------------------------------- Chapter 1:3.2

Federal Reimbursement for Foster Care (Letter, 8/11/95,
GAO/HEHS-95-197R). 

Penson COLAs (Letter, 8/11/95, GAO/HEHS-95-219R). 

Combined Fund Analysis (Letter, 8/7/95, GAO/HEHS-95-230R). 


   VETERANS AFFAIRS AND MILITARY
   HEALTH
---------------------------------------------------------- Chapter 1:4


      SELECTED SUMMARIES
-------------------------------------------------------- Chapter 1:4.1

VA Health Care:  Need for Brevard Hospital Not Justified (Report,
8/29/95, GAO/HEHS-95-192). 

The Department of Veterans Affairs (VA) conversion of the former
Orlando Naval Hospital into a nursing home and construction of a new
hospital and nursing home in Brevard County is not the most prudent
and economical use of its resources.  VA could achieve its service
goals in Central Florida by using existing capacity rather than
building a 470-bed VA hospital and 120-bed nursing home in Brevard
County and converting the former Naval Hospital to a nursing home. 
For example, VA could purchase care from community nursing homes to
meet veterans' needs more conveniently and at a lower cost.  This
would allow VA to use the former Orlando Naval Hospital to improve
the geographic accessibility of VA medical and psychiatric care. 
Also, VA's three Central Florida hospitals have over 400 unused
medical and surgical beds; many of these could be converted to
psychiatric beds.  VA's existing hospitals may be more geographically
accessible to veterans, given that about 59 percent of the expected
psychiatric use of the proposed Brevard hospital would be generated
by veterans from other areas of Florida.  VA's consideration of such
alternatives would ensure that its planning strategy focuses on the
most prudent and economical use of resources throughout the network
of Florida VA facilities. 


Defense Health Care:  Despite TRICARE Procurement Improvements,
Problems Remain (Report, 8/3/95, GAO/HEHS-95-142). 

In sustaining the protest of the Department of Defense's (DOD)
California/Hawaii contract award, GAO cited several problems,
including DOD's failure to evaluate offerors' proposed prices
according to solicitation criteria, lack of communication between DOD
evaluators performing technical and price evaluations, and failure to
properly evaluate offerors' cost containment approaches such as their
proposed methods for controlling health care service use.  In
response, DOD changed its managed care procurement processes in
several ways to correct these and other problems.  In GAO's view,
DOD's changes should improve future procurements and ensure more
equitable and fair treatment of offerors.  They are unlikely,
however, to eliminate future protests.  Despite DOD's improvements,
several matters remain that concern both those administering and
those responding to the procurements. 


      OTHER VETERANS AFFAIRS AND
      MILITARY HEALTH PRODUCTS
-------------------------------------------------------- Chapter 1:4.2

VA Construction Contract Award Delays (Letter, 8/25/95,
GAO/HEHS-95-240R). 


MAILING LIST REQUEST FORM
============================================================ Chapter 2


         ADDRESS INFORMATION
------------------------------------------------------ Chapter 2:0.0.1

To receive this booklet each month, check here:  .

Name: 
Organization: 
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Which of the following best describes your organization? 

Congress (2) Other Federal Government (8)
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University (6) Law Firm (11)
Private Industry (7) All Others (99)


         AREAS OF INTEREST
------------------------------------------------------ Chapter 2:0.0.2

To receive future reports and testimonies, check your area(s) of
interest. 

HEALTH EMPLOYMENT
Access/Infrastructure (78) Equal Opportunities (00)
Employee/Retiree Benefits (77) High Performance Work (38)
Financing (64) Labor/Mgt.Relations (57)
Health Care Reform (85) Training/Employment
HHS Public Health Service (8) Assistance (60)
Long-Term Care/Aging (73) Workplace Quality (7)
Malpractice (79) Other Employment Issues (47)
Managed Care (80)
Medicare/Medicaid (11) SOCIAL SECURITY, DISABILITY,
Prescription Drugs (81) & WELFARE
Provider Issues (82) Children's Issues (59)
Public Health/Education (83) Pensions (61)
Quality/Practice Standards (25) Social Security & Disability (58)
Substance Abuse/Treatment (84) Welfare (75)
Other Health Issues (86) Other Social Security, Disability
& Welfare Issues (96)
EDUCATION
Department of Education (27)
Early Childhood Develop.  (70) VETERANS AFFAIRS & MILITARY
Armed Forces (35) HEALTH
Elementary/Secondary (2) Military Health (5)
Higher Education (39) Veterans' Benefits (74)
School-to-Work Transition (1) Veterans' Health Care (10)


         FAX OR MAIL TO: 
------------------------------------------------------ Chapter 2:0.0.3

Janet Shikles, Assistant Comptroller General
Health, Education, and Human Services Division, NGB/ACG
U.S.  General Accounting Office
441 G Street, N.W., Washington, D.C., 20548


         (9/95)
------------------------------------------------------ Chapter 2:0.0.4

Fax (202) 512-5806



CHANGE OF ADDRESS NOTIFICATION
FORM
============================================================ Chapter 3


         REQUESTING CHANGES
------------------------------------------------------ Chapter 3:0.0.1

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         FAX OR MAIL TO: 
------------------------------------------------------ Chapter 3:0.0.2

Janet Shikles, Assistant Comptroller General
Health, Education, and Human Services Division, NGB/ACG
U.S.  General Accounting Office
441 G Street, N.W., Washington, D.C., 20548


         (9/95)
------------------------------------------------------ Chapter 3:0.0.3

Fax (202) 512-5806



INTERNET INSTRUCTIONS
============================================================ Chapter 4

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