Health Care Delivery and Quality Issue Area Plan--Fiscal Years 1996-98
(Letter Report, 09/01/95, GAO/IAP-95-35).

GAO presented its Health Care Delivery and Quality issue area plan for
fiscal years 1996 through 1998.

GAO plans to assess: (1) ways to improve the quality of and access to
health care financed by federal agencies; (2) how the Departments of
Veterans Affairs' (VA) and Defense's (DOD) programs and systems could
operate more efficiently and effectively and whether they should be
restructured in the face of declining patient workloads; (3) how well
DOD is implementing its managed care program; (4) how to control health
care costs without compromising quality and access; (5) the
applicability of private sector best practices; and (6) pension and
disability programs, particularly regarding their eligibility
requirements and duplication of and reimbursement from other programs.

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

 REPORTNUM:  IAP-95-35
     TITLE:  Health Care Delivery and Quality Issue Area Plan--Fiscal 
             Years 1996-98
      DATE:  09/01/95
   SUBJECT:  Managed health care
             Veterans benefits
             Veterans hospitals
             Health care services
             Military personnel
             Dependents
             Health care programs
             Health care cost control
             Quality assurance
             Health services administration
IDENTIFIER:  Medicaid Program
             Civilian Health and Medical Program of the Uniformed 
             Services
             Medicare Program
             DOD TRICARE Program
             VA Veterans Integrated Service Network
             Federal Employees Health Benefits Program
             CHAMPUS
             
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Cover
================================================================ COVER


Health, Education, and Human Services Division

September 1995

HEALTH CARE DELIVERY AND QUALITY
ISSUE AREA PLAN

FISCAL YEARS 1996-98

GAO/IAP-95-35



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


FOREWORD
============================================================ Chapter 0

As the investigative arm of Congress and the nation's auditor, the
General Accounting Office is charged with following the federal
dollar wherever it goes.  Reflecting stringent standards of
objectivity and independence, GAO's audits, evaluations, and
investigations promote a more efficient and cost-effective
government; expose waste, fraud, abuse, and mismanagement in federal
programs; help Congress target budget reductions; assess financial
and information management; and alert Congress to developing trends
that may have significant fiscal or budgetary consequences.  In
fulfilling its responsibilities, GAO performs original research and
uses hundreds of databases or creates its own when information is
unavailable elsewhere. 

To ensure that GAO's resources are directed toward the most important
issues facing Congress, each of GAO's 35 issue areas develops a
strategic plan that describes the significance of the issues it
addresses, its objectives, and the focus of its work.  Each issue
area relies heavily on input from congressional committees, agency
officials, and subject-matter experts in developing its strategic
plan. 

The Health Care Delivery and Quality issue area covers health care
services provided to veterans and military beneficiaries through the
Departments of Veterans' Affairs' (VA) and Defense's (DOD) systems of
hospitals and clinics.  Our quality of care work includes the care
provided directly by the federal government (VA, DOD, Indian Health
Service, and Bureau of Prisons) and care financed under Medicare and
Medicaid.  Our work at VA also evaluates programs providing certain
nonhealth benefits, such as disability compensation and pensions, to
veterans and their dependents or survivors. 

The principal issues in this issue area are

  -- improving the quality of the nation's health care;

  -- improving the efficiency and effectiveness of VA and DOD health
     care systems and VA benefit programs;

  -- restructuring the VA and DOD health care and VA benefits systems
     to better accomplish their missions; and

  -- improving the implementation of managed care in DOD. 

In the pages that follow, we describe our key planned work on these
issues. 

Because events may significantly affect even the best of plans, our
planning process allows for updating the plan and responding quickly
to emerging issues.  If you have any questions or suggestions about
this plan, please call me at (202) 512-7101. 

David P.  Baine
Director
Health Care Delivery and Quality Issues


CONTENTS
============================================================ Chapter 1


   FOREWORD
---------------------------------------------------------- Chapter 1:1

1


   TABLE I:  KEY ISSUES
---------------------------------------------------------- Chapter 1:2

4


   TABLE II:  PLANNED MAJOR WORK
---------------------------------------------------------- Chapter 1:3

6


   TABLE III:  GAO CONTACTS
---------------------------------------------------------- Chapter 1:4

7


TABLE I:  KEY ISSUES
============================================================ Chapter 2

Issue                    Significance
-----------------------  -------------------------------------------------------
Quality of care: How     The federal government delivers health care to millions
can the quality of the   of people each year through the huge DOD and VA health
nation's health care be  care systems as well as through smaller programs such
improved?                as the Indian Health Service and the Bureau of Prisons.
                         Millions more are affected by the health care funded by
                         Medicare and Medicaid. As Congress considers ways to
                         curb rising health care costs and make further cuts to
                         control the deficit, information about existing quality
                         problems and ways Congress can safeguard quality of
                         care will be crucial.







VA and DOD efficiency    DOD and VA operate two of the largest health care
and effectiveness: How   systems in the world. For example, VA has 173
can VA and DOD health    hospitals, 376 outpatient clinics, 136 nursing homes,
care systems and VA      and 39 domiciliaries. DOD also funds a major insurance
benefits programs, as    program for care in private-sector facilities, the
currently structured,    Civilian Health and Medical Program of the Uniformed
operate more             Services (CHAMPUS). It costs about $30 billion each
efficiently and          year to operate the federal systems and CHAMPUS. VA
effectively?             also provides other benefits to veterans and their
                         dependents or survivors. For example, compensation and
                         pension benefits to about 3.3 million recipients cost
                         over $16 billion in fiscal year 1994 and were
                         administered through 58 regional offices. Ensuring the
                         efficient and effective delivery of these health and
                         other benefits is a major challenge.








VA and DOD               VA and DOD health care systems face increasing
restructuring: Can the   challenges from a changing health care marketplace as
missions of the VA and   well as pressures to reduce health care costs. A
DOD health care and VA   continuing decline in patient workload threatens the
benefits systems be      economic viability of VA hospitals while, at the same
better accomplished in   time, veterans have unequal access to health care. The
the future by            military health care system must adjust to new post-
restructuring the        Cold War planning scenarios and substantial reductions
systems?                 in the overall size of the nation's military forces.
                         Pressure to reduce the deficit also increases attention
                         on nonhealth benefits for veterans, military retirees,
                         and their dependents and survivors, where there are
                         significant issues regarding eligibility and potential
                         overlap and duplication in delivery systems.





DOD managed care         By May 1997, DOD expects to have implemented nationwide
implementation:          its new TRICARE program, offering managed health care
How well is managed      to more than 5 million beneficiaries at a cost of $17
care being implemented   billion over 5 years. Designing and implementing a
in DOD?                  managed care program on this scale is unprecedented and
                         poses significant challenges. At the same time,
                         understanding the lessons learned from DOD's experience
                         will benefit the private sector and other government
                         programs.






--------------------------------------------------------------------------------
Objectives                    Focus of work
----------------------------  --------------------------------------------------
--Identify ways to improve    ï¿½ Health care provider quality
quality of care provided by
federal agencies or financed  ï¿½ Direct care processes
with federal funds.
                              ï¿½Measurement of health care quality, especially
--Enhance the current body    outcomes
of knowledge and discussion
on evaluation and delivery
of quality care.

--Identify the quality
implications of anticipated
or proposed legislative
health care initiatives.


--Identify more effective     ï¿½ Changes in operating procedures
management controls to
minimize fraud, waste, and    ï¿½ Quality assurance and improvement efforts
abuse.
                              ï¿½ Budgeting and spending activities
--Identify ways to save
millions of dollars through
legislative or
administrative changes that
improve overall operational
efficiency.

--Identify ways to improve
services to veterans.

--Evaluate management
initiatives to determine how
well they address underlying
problems.


--Identify options for        ï¿½ Organizational relationships within VA and among
restructuring service         VA, DOD, and other government programs
delivery systems.
                              ï¿½ Eligibility for health care and nonhealth
--Identify options for        benefits
better targeting benefits to
veterans and military         ï¿½Size and structure of military health services
personnel and their           system
dependents.

--Identify needed changes in
military medicine
requirements, organization,
or structure in response to
changing military force
structure and demographics.


--Identify lessons learned    ï¿½ TRICARE policies
from DOD's managed care
experience.                   ï¿½TRICARE implementation issues

--Identify needed changes in
DOD's managed care
strategies, designs,
policies, and plans.

--Identify ways to improve
the implementation of
managed care for
beneficiaries and the
government.

--------------------------------------------------------------------------------

TABLE II:  PLANNED MAJOR WORK
============================================================ Chapter 3

Issue               Planned major job starts
------------------  --------------------------------------------------
Quality of care     --Examine quality implications of increased use of
                    nonphysician providers.
                    --Examine potential of telemedicine to improve
                    delivery of quality care.
                    --Assess appropriateness of physician workloads in
                    VA, DOD, and the private sector.
                    --Identify alternative useful quality assurance
                    models for Medicare programs.

VA and DOD          --Evaluate VA's internal processes for sharing
efficiency and      information about innovations.
effectiveness       --Assess VA's efforts to improve its benefit
                    claims processing functions.
                    --Evaluate use of "best practices" in the VA and
                    DOD health care systems.
                    --Assess VA's central office quality assurance and
                    oversight of benefits programs.
                    --Review VA and DOD budget submissions and
                    controls over spending activities.
                    --Assess DOD and VA third party collection
                    programs.
                    --Identify extent of duplicate billings under VA's
                    fee basis and contract hospital and nursing home
                    programs.
                    --Examine VA's purchase and use of high technology
                    and durable medical equipment.
                    --Assess status of improvements in VA's
                    construction program.

VA and DOD          --Evaluate implications of VA's new Veterans
restructuring       Integrated Service Network.
                    --Evaluate implementation/effect of VA's increased
                    emphasis on primary care.
                    --Monitor effects of state health reforms on VA
                    health care facilities.
                    --Assess the need for separate VA and DOD
                    disability compensation systems.
                    --Assess the relationship between VA's pension
                    program and Social Security.
                    --Evaluate VA's health care eligibility reform
                    proposals.
                    --Evaluate adequacy of VA's disability rating
                    schedule to meet congressional intent.
                    --Determine impact on the budget and individuals
                    of reducing or ending compensation for low-rated
                    disabilities.
                    --Assess proposals for VA to be reimbursed for
                    serving Medicare-eligible veterans.
                    --Identify options for DOD's serving Medicare-
                    eligible retirees.
                    --Compare analyses and recommendations of the
                    Commission on Base Closure and Realignment's Joint
                    Cross-Service Working Group on Military Hospitals
                    and the Services.
                    --Assess the merit of consolidating the three
                    military medical departments into a single
                    department.
                    --Assess the desirability of including military
                    health care beneficiaries in the Federal Employees
                    Health Benefits Program.

DOD managed care    --Examine TRICARE Prime's enrollment system.
implementation      --Examine cost-effectiveness of TRICARE.
                    --Assess progress toward a more uniform military
                    health care benefit package.
                    --Examine the financing of TRICARE.
----------------------------------------------------------------------

TABLE III:  GAO CONTACTS
============================================================ Chapter 4


      DIRECTOR
-------------------------------------------------------- Chapter 4:0.1

David Baine (202) 512-7101


      ASSOCIATE DIRECTOR
-------------------------------------------------------- Chapter 4:0.2

Carlotta Joyner (202) 512-7101


      ASSISTANT DIRECTORS
-------------------------------------------------------- Chapter 4:0.3

Daniel Brier
James Carlan
Irene Chu
Ruth Ann Heck
Sandra Isaacson
James Linz
Clarita Mrena
George Poindexter
Paul Reynolds

*** End of document. ***