Health Services Quality and Public Health Issue Area Plan--Fiscal Years
1998-1999 (Letter Report, 05/01/97, GAO/IAP-97-14).

GAO provided information on its Health Services Quality and Public
Health issue area plan for fiscal years 1998 and 1999.

GAO plans to: (1) determine whether the public health service agencies
are ensuring the public's health and safety efficiently and effectively;
(2) assess opportunities for improving the quality of health care under
fee-for-service and managed care payment arrangements; (3) assess
opportunities for improving the nation's access to health care; and (4)
assess the implications of emerging health care technologies.

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

 REPORTNUM:  IAP-97-14
     TITLE:  Health Services Quality and Public Health Issue Area 
             Plan--Fiscal Years 1998-1999
      DATE:  05/01/97
   SUBJECT:  Health care services
             Health services administration
             Health care cost control
             Public health research
             Managed health care
             Health care programs
             Health insurance
             Medical research
             Medical information systems
             Pharmaceutical industry
IDENTIFIER:  Medicare Program
             Medicaid Program
             HCFA Utilization and Quality Control Peer Review 
             Organization Program
             
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Cover
================================================================ COVER


Health, Education, and Human Services Division

June 1997

HEALTH SERVICES QUALITY AND PUBLIC
HEALTH ISSUES

ISSUE AREA PLAN FOR FISCAL YEARS
1998 AND 1999

GAO/IAP-97-14



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


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

As the investigative arm of the 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 fraud, waste, abuse, and mismanagement in federal
programs; help the Congress target budget reductions; assess
financial and information management; and alert the 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 the Congress, each of GAO's 32 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 Services Quality and Public Health issue area is
responsible for GAO's work on national and public health issues.  The
issue area focuses on evaluating individuals' access to high-quality
care in a changing health care environment and on measuring the
outcomes and effectiveness of federally funded programs, research,
and regulatory activities.  The issue area's operational oversight
includes the programs of the Food and Drug Administration (FDA), the
National Institutes of Health (NIH), the Health Resources and
Services Administration (HRSA), the Substance Abuse and Mental Health
Services Administration (SAMHSA), the Centers for Disease Control and
Prevention (CDC), and other public health service agencies in the
Department of Health and Human Services (HHS). 

GAO's work on health services quality and public health issues
generally focuses on the following issues: 

  determining whether the public health service agencies are ensuring
     the public's health and safety efficiently and effectively,

  assessing opportunities for improving the quality of health care
     under fee-for-service and managed care payment arrangements,

  assessing opportunities for improving the nation's access to health
     care, and

  assessing the implications of emerging health care technologies. 

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

Because events may significantly affect even the best of plans and
because periodic measurement of success against any plan is
essential, our planning process allows for updating and provides
flexibility to respond quickly to emerging issues.  If you have any
questions or suggestions about this plan, please call me at (202)
512-7119. 

Bernice Steinhardt
Director
Health Services Quality and Public Health 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                                      Objectives                                        Focus of work
---------------------------------------  ------------------------------------------------  ------------------------------------------------  ---------------------------------------
Public health: How efficiently and       HHS' eight major public health agencies are       Assess the implications for public health of     Reauthorization of public health
effectively are federal agencies and     undergoing changes, partly because of budget      shifting roles and responsibilities among         agencies.
public institutions ensuring the         constraints and interest in devolving federal     federal, state, and local governments and the     Agency development of performance
public's                                 responsibilities to states and the private        private sector.                                   measures and progress toward goals in
health and safety?                       sector. These organizational shifts occur amid    Examine various approaches for ensuring the      public health programs.
                                         concern about the adequacy of efforts to          public's health and safety, the cost of those     Public health agencies' research and
                                         prevent, control, and treat public health         approaches, and the levels of protection they     services related to the health of at-
                                         problems such as AIDS, drug use by adolescents,   afford.                                           risk youth.
                                         and rising rates of chronic disease. There are    Assess the capacity of public health agencies    Appropriateness, effectiveness, and
                                         also concerns about the regulatory process used   and programs to                                   efficiency of FDA's regulation of
                                         to monitor the development and marketing of new   meet public health needs.                         drugs, devices, and biologics.
                                         drugs, medical devices, and other medical         Assess federal oversight activities to ensure    Effectiveness and cost of federal
                                         products. In response to these concerns and a     accountability and the effective use of federal   transplantation programs.
                                         changing health care environment, some HHS        public health dollars.                            Condition of the public health
                                         agencies are modifying their procedures and                                                         infrastructure at the state and local
                                         adopting strategies to improve performance. By                                                      levels.
                                         requiring agencies to develop strategic plans                                                       Substance abuse prevention and
                                         and goals and to measure their performance, the                                                     treatment.
                                         Government Performance and Results Act provides
                                         a useful vehicle for the Congress for obtaining
                                         evidence on how well agency initiatives work.

Quality of care: Given pressures to      Efforts to control health care spending have      Evaluate the validity, reliability, and utility  Managed care organizations' monitoring
control costs, what measures should be   implications for the quality of health care.      of information on quality.                        of quality of care.
taken to ensure the quality of the       While the transition to an increasingly managed   Evaluate HCFA's efforts to maintain and improve  Oversight of quality of care in
nation's health care?                    care market has potential benefits, it also       quality of care in the Medicare and Medicaid      government-financed health programs.
                                         introduces risks that providers will use cost-    programs.                                         Use of information on quality by
                                         control measures that compromise access to        Examine the implications for quality of how      consumers, payers, and providers.
                                         quality care. These benefits and risks are faced  health care is financed                           Comparisons of process and outcome for
                                         not only by private purchasers of care but also   and structured.                                   patients treated under different
                                         by public purchasers, including the Medicare and  Identify opportunities for improving quality     financing arrangements.
                                         Medicaid programs. As the Congress considers      while reducing health care costs of federal       Opportunities for savings by
                                         ways to curb rising health care costs, it needs   programs.                                         identifying ineffective treatments and
                                         information about the consequences of market      Evaluate private sector efforts to improve       procedures in the Medicare and Medicaid
                                         changes for various dimensions of quality,        quality and reduce costs                          programs.
                                         including the appropriateness of care, health     that could serve as models for federal programs.  Federal efforts to improve physician
                                         outcomes, and patient satisfaction. The Congress                                                    practices.
                                         also needs information on the quality of care
                                         provided to Medicare and Medicaid beneficiaries
                                         under existing fee-for-service arrangements.

Access to care: How can the federal      Millions of Americans face barriers to health     Improve understanding of the barriers people     Access to care by uninsured and
government ensure access to health care  care because they are uninsured. Additionally,    face in obtaining                                 medically underserved populations.
for all Americans?                       some people with health coverage may be           health care.                                      Access to preventive services.
                                         inadequately insured for their medical needs or   Evaluate the adequacy of the mix and             Managed care organizations' provision
                                         have insurers who place restrictions on their     distribution of health care providers.            of services for the chronically ill.
                                         access to care. Still others face barriers        Assess the health and cost consequences of       Federal and state policies shaping the
                                         because they live in areas that have an           inadequate access to care.                        supply and mix of health providers.
                                         inadequate supply or mix of health providers.     Identify trends in access to specific services   Access to mental health and substance
                                         There is growing concern about the ability of     under managed care                                abuse services.
                                         public hospitals, clinics, and other federally    and fee-for-service payment arrangements.
                                         supported providers to continue to serve
                                         uninsured and other vulnerable populations in
                                         the increasingly competitive and cost-conscious
                                         health care environment. In addition, it is not
                                         clear how well federal programs intended to
                                         improve access are achieving their goals. The
                                         Congress, therefore, will need information on
                                         whether these programs are fulfilling their
                                         missions and on how changes in the financing and
                                         delivery of health care affect vulnerable
                                         populations' access to care.

Emerging technologies in health care:    The development of new knowledge and medical      Examine public and private mechanisms for        The movement of therapies from
How will advancements in research,       technology in areas such as human genetics, drug  evaluating medical interventions.                 "experimental" to conventional status.
technology, and information systems      testing, computerized patient records, and        Assess the implications of the increased         Patient confidentiality and the trade-
affect the public's health and           transplantation raises many ethical and legal     availability of health-related information on     offs involved in using data for
patients' rights?                        issues. The 1996 Health Insurance Portability     individuals.                                      research and quality assurance.
                                         and Accountability Act, for example, requires     Review compliance with current federal policies  The uses of biogenetic material and
                                         the development of an extensive health            regarding the                                     information.
                                         information network that will make information    conduct of biomedical and behavioral research.
                                         more readily accessible but less private.
                                         Conflicts also arise in considering how to make
                                         available the benefits of new technologies, such
                                         as organ transplantation or new AIDS drugs, when
                                         costs are high and supplies are limited.
                                         Providing the Congress with information on how
                                         advancements in science and technology are used
                                         and accepted, while also evaluating the trade-
                                         offs involved, will help inform congressional
                                         deliberations.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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

Issue               Planned major job starts
------------------  ------------------------------------------------------------
Public health       Examine the capacity of federal, state, and local
                    government agencies to conduct public health surveillance
                    activities.
                    Identify opportunities to increase the efficiency of the
                    clinical phase of drug development.
                    Examine FDA's regulation of the advertising and promotion
                    activities of pharmaceutical companies.
                    Evaluate the adequacy of surveillance and enforcement
                    operations associated with importing human drugs from
                    overseas.
                    Examine third-party review and approval of medical
                    devices.
                    Evaluate how FDA has used the revenues obtained from
                    prescription drug user fees.
                    Review FDA's oversight of human tissue banking.
                    Evaluate the appropriateness of federal reimbursement of
                    organ acquisition charges.
                    Assess the effectiveness of federal programs in increasing
                    organ donations.
                    Evaluate the effectiveness of adult and youth drug
                    treatment programs.
                    Examine the capability of public health agencies to deter
                    drug epidemics.
                    Identify strategies states are using to prevent teen
                    pregnancies and out-of-wedlock births in light of welfare
                    reform incentives.

Quality of care     Examine validity and reliability of commonly used
                    performance measurement systems.
                    Compare treatments and outcomes of heart attack patients
                    under Medicare managed care and fee-for-service plans.
                    Identify cost savings available through elimination of
                    unnecessary treatments and tests in the Medicare fee-for-
                    service program.
                    Examine impact of restrictive formularies and "drug
                    switching" programs on quality of care for Medicare and
                    Medicaid beneficiaries enrolled in risk HMOs.
                    Examine the nature and extent of problems related to
                    consumer protection and quality of care in assisted living
                    facilities.
                    Examine the quality of care available to end-stage renal
                    disease patients in Medicare HMOs.
                    Examine the effectiveness of HCFA's approach for improving
                    quality through Peer Review Organizations.
                    Examine implementation of the Nursing Home Quality
                    Standards Act.
                    Examine quality assurance and improvement systems that
                    managed care organizations have in place to ensure that
                    enrollees obtain necessary and appropriate care.

Access to care      Examine the health and cost consequences for children
                    lacking insurance coverage.
                    Examine the impact of federal financing of graduate medical
                    education on the mix and distribution of health providers in
                    medically underserved communities.
                    Assess differences in access to specialized hospital
                    services for Medicare beneficiaries enrolled in fee-for-
                    service and HMOs.
                    Examine the implications of Medicaid's transition to
                    managed care on the care available to the uninsured.
                    Assess how Medicaid managed care affects the quality of and
                    access to mental health services.
                    Examine implications of not-for-profit hospital conversions
                    on availability of care for the uninsured and other
                    vulnerable populations.

Emerging            Determine how payers decide when to reimburse for an
technologies in     "experimental" therapy.
health care         Evaluate HHS' implementation of the data confidentiality
                    and access provisions of the Health Insurance Portability
                    and Accountability Act.
                    Determine the prevalence of genetic testing as a condition
                    of employment or acquiring health insurance.
--------------------------------------------------------------------------------

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


   DIRECTOR
---------------------------------------------------------- Chapter 4:1

Bernice Steinhardt (202) 512-7119


   ASSOCIATE DIRECTOR
---------------------------------------------------------- Chapter 4:2

Marsha Lillie-Blanton (202) 512-7119


   ASSISTANT DIRECTORS
---------------------------------------------------------- Chapter 4:3

Marcia Crosse
John Hansen
Sandra Isaacson
Rosamond Katz
James McClyde
Frank Pasquier (Seattle)
George Silberman

*** End of document. ***