Major Management Challenges and Program Risks: Department of Health and
Human Services (Letter Report, 01/01/99, GAO/OCG-99-7).

As part of its Performance and Accountability Series, GAO provided
information on the major management challenges and program risks facing
the Department of Health and Human Services (HHS).

GAO noted that: (1) coordinating the efforts of the numerous
administrators of HHS' programs, including its 11 agencies and state and
local governments, is critical to ensuring program efficiency and
effectiveness; (2) HHS must also coordinate with a number of other
federal, state, and local agencies that have programs with similar
goals; (3) while HHS recognizes this need, it has not delineated how it
plans to ensure effective program coordination; (4) HHS does not have
access to the data needed to effectively manage the Department's
extensive health insurance programs, grant-making activities, and
regulatory responsibilities; (5) developing and maintaining systems to
ensure access to such data, however, is challenging since many important
HHS programs are administered by program partners, such as state and
local governments; (6) yet, without these systems, HHS cannot adequately
oversee its programs; (7) maintaining the integrity of HHS' large
programs, especially Medicare, continues to be a challenge; (8) although
legislation has been enacted in the past 2 years to bolster the Health
Care Financing Administration's (HCFA) oversight capacity, initiatives
to curb fraud, waste, abuse, and mismanagement have been slow to
develop; (9) HHS' Office of the Inspector General reported that HHS and
its operating divisions do not have a fully functional integrated
financial reporting system capable of producing complete and reliable
financial statements in a timely manner; (10) as required by the
Government Performance and Results Act of 1993, HHS submitted to
Congress a strategic plan for fiscal years 1998-2003; and (11) while
this 5-year plan and the Department's 1999 performance plan provide
general information about how HHS intends to address these challenges,
HHS needs to do more to ensure that its programs achieve intended
results and that it is an effective steward of taxpayer dollars.

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

 REPORTNUM:  OCG-99-7
     TITLE:  Major Management Challenges and Program Risks: Department 
             of Health and Human Services
      DATE:  01/01/99
   SUBJECT:  Health care programs
             Accountability
             Interagency relations
             Medical information systems
             Risk management
             Management information systems
             Intergovernmental relations
             Strategic planning
             Program abuses
             Information resources management
IDENTIFIER:  Performance and Accountability Series 1999
             Medicare Hospital Insurance Trust Fund
             Y2K
             HHS Temporary Assistance for Needy Families Program
             Head Start Program
             Maternal and Child Health Block Grant
             State Children's Health Insurance Program
             Medicare Program
             Medicaid Program
             Medicare Choice Program
             Medicare Prospective Payment System
             
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Cover
================================================================ COVER


Performance and Accountability Series

January 1999

MAJOR MANAGEMENT CHALLENGES AND
PROGRAM RISKS - DEPARTMENT OF
HEALTH AND HUMAN SERVICES

GAO/OCG-99-7

HHS Challenges


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

  ACF - Administration for Children and Families
  BBA - The Balanced Budget Act of 1997
  CDC - Centers for Disease Control
  FDA - Food and Drug Administration
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  HIPAA - Health Insurance Portability and Accountability Act of 1996
  IHS - Indian Health Service
  OIG - Office of Inspector General
  PPS - prospective payment systems
  SAMHSA - Substance Abuse and Mental Health Services Administration
  SCHIP - State Children's Helth Insurance Program
  SNF - skilled nursing facility

Letter
=============================================================== LETTER



January 1999

The President of the Senate
The Speaker of the House of Representatives

This report addresses the major performance and management challenges
that face the Department of Health and Human Services (HHS) in
carrying out its mission.  It also addresses corrective actions that
HHS has taken or initiated to meet these challenges and further
actions that are needed.  For many years, we have reported
significant management problems at HHS.  These problems are the
result of deficiencies in the coordination and oversight of HHS'
numerous programs, the data and data systems needed to manage these
programs, and efforts to safeguard program integrity.  The problems
are particularly critical for the Medicare program--our nation's
largest health care insurer. 

HHS is making progress in developing a framework for improving the
way the Department is managed.  HHS' strategic and performance plans
demonstrate the Department's commitment to more effectively and
efficiently manage its broad range of programs that are vital to the
well-being of the American people.  Management reforms--including
changes to the Medicare program--are under way, but many are in the
early stages of implementation.  Given the nature and extent of the
challenges facing HHS in its management of the Medicare program, it
will take time and sustained attention from senior officials to
implement reforms and assess their impact.  Consequently, we believe,
as we previously reported in 1995 and 1997, that these management
deficiencies, taken together, continue to place the integrity and
accountability of the Medicare program at high risk. 

This report is part of a special series entitled the Performance and
Accountability Series:  Major Management Challenges and Program
Risks.  The series contains separate reports on 20 agencies--one on
each of the cabinet departments and on most major independent
agencies as well as the U.S.  Postal Service.  The series also
includes a governmentwide report that draws from the agency-specific
reports to identify the performance and management challenges
requiring attention across the federal government.  As a companion
volume to this series, GAO is issuing an update to those government
operations and programs that its work has identified as "high risk"
because of their greater vulnerabilities to waste, fraud, abuse, and
mismanagement.  High-risk government operations are also identified
and discussed in detail in the appropriate performance and
accountability series agency reports. 

The performance and accountability series was done at the request of
the Majority Leader of the House of Representatives, Dick Armey; the
Chairman of the House Government Reform Committee, Dan Burton; the
Chairman of the House Budget Committee, John Kasich; the Chairman of
the Senate Committee on Governmental Affairs, Fred Thompson; the
Chairman of the Senate Budget Committee, Pete Domenici; and Senator
Larry Craig.  The series was subsequently cosponsored by the Ranking
Minority Member of the House Government Reform Committee, Henry A. 
Waxman; the Ranking Minority Member, Subcommittee on Government
Management, Information, and Technology, House Government Reform
Committee, Dennis J.  Kucinich; Senator Joseph I.  Lieberman; and
Senator Carl Levin. 

Copies of this report series are being sent to the President, the
congressional leadership, all other Members of the Congress, the
Director of the Office of Management and Budget, the Secretary of
Health and Human Services, and the heads of other major departments
and agencies. 

David M.  Walker
Comptroller General of
the United States


OVERVIEW
=========================================================== Appendix 0

The Department of Health and Human Services (HHS) is responsible for
administering many diverse and complex programs to improve the health
and well-being of the American people.  In fiscal year 1998, HHS had
budget outlays totaling over $359 billion and a workforce of over
57,000 employees.  Medicare, the nation's largest health care
insurer, spends far more than most cabinet departments; last year, it
handled an estimated 800 million claims and paid out about $200
billion.  In addition, HHS is the largest federal grant-making
agency, providing approximately 60,000 grants a year. 

As HHS fulfills this broad range of responsibilities, it faces a
number of major performance and management challenges.  One of the
most serious challenges is the solvency of Medicare's Hospital
Insurance Trust Fund, which funds Medicare part A.  In its 1998
annual report, the Fund's trustee board projected that the Trust Fund
faces rapidly escalating deficits and will be depleted by 2008.  The
Medicare Bipartisan Commission is currently exploring various options
to extend Medicare's financial viability in the long term.  Beyond
this critical issue, HHS faces a number of performance and management
challenges that have been identified by GAO and HHS' Office of
Inspector General (OIG). 

THE CHALLENGES


      SCOPE AND COMPLEXITY OF HHS
      PROGRAMS CREATE CHALLENGES
      WITH COORDINATION,
      OVERSIGHT, AND PERFORMANCE
      MEASUREMENT
------------------------------------------------------- Appendix 0:0.1

Coordinating the efforts of the numerous administrators of HHS'
programs--which include HHS' 11 agencies and state and local
governments--is critical to ensuring program efficiency and
effectiveness.  HHS must also coordinate with a number of other
federal, state, and local agencies that have programs with similar
goals.  While HHS recognizes this need, it has not delineated how it
plans to ensure effective program coordination.  Certain program
characteristics--such as those that provide states the flexibility to
design their own programs--make coordination of effort and oversight
a daunting task.  Compounding this difficulty is the need for the
Department to develop adequate performance measures that ensure
accountability. 


      HHS NEEDS RELIABLE AND
      COMPREHENSIVE DATA AND DATA
      SYSTEMS TO MANAGE PROGRAMS
      AND ASSESS RESULTS
------------------------------------------------------- Appendix 0:0.2

HHS does not have access to the data needed to effectively manage the
Department's extensive health insurance programs, grant-making
activities, and regulatory responsibilities.  Developing and
maintaining systems to ensure access to such data, however, is
challenging since many important HHS programs are administered by
program partners, such as state and local governments.  Yet without
these systems, HHS cannot adequately oversee its programs.  Technical
concerns about computer capabilities posed by the year 2000 add
further complexity to this challenge.  Of particular concern is the
possible interruption of Medicare services and payments. 


      PROGRAM INTEGRITY IS A
      CONTINUING CHALLENGE FOR HHS
------------------------------------------------------- Appendix 0:0.3

Maintaining the integrity of HHS' large programs, especially
Medicare, continues to be a challenge.  In the past, we have
designated Medicare as a high-risk area, and it remains one. 
Although legislation has been enacted in the past 2 years to bolster
the Health Care Financing Administration's (HCFA) oversight
capability, initiatives to curb fraud, waste, abuse, and
mismanagement have been slow to develop.  Specifically, HCFA has been
slow to implement its new authority to perform Medicare payment
safeguard activities.  In addition, the implementation of new payment
systems that are intended to curb rapid spending increases in the
Medicare program have been stalled because HCFA needs to get its
critical data systems ready for the year 2000.  Furthermore,
implementation difficulties threaten the success of HCFA's
Medicare+Choice program.  HHS' financial statement audits also
continue to have problems.  Specifically, HHS' inability to provide
adequate support for certain financial statement amounts, such as
Medicare accounts receivable and grant accrual expenses, contributed
to the OIG issuing a qualified opinion on HHS' fiscal year 1997
financial statements.  In addition, the OIG reported that HHS and its
operating divisions do not have a fully functional integrated
financial reporting system capable of producing complete and reliable
financial statements in a timely manner. 

PROGRESS AND NEXT STEPS

As required by the Government Performance and Results Act of 1993,
commonly known as the Results Act, HHS submitted to the Congress a
strategic plan for fiscal years 1998-2003.  While this 5-year plan
and the Department's 1999 performance plan provide general
information about how HHS intends to address these challenges, HHS
needs to do more to ensure that its programs achieve intended results
and that it is an effective steward of taxpayer dollars. 

HHS' strategic and performance plans acknowledge the need for
internal and external coordination.  However, HHS needs to provide
more information about how it will coordinate with the state, local,
and tribal governments; contractors; and private entities that are
its program and information partners.  To strengthen program
accountability, HHS needs to continue its efforts to develop more
outcome measures for assessing the results of its programs. 

HHS' strategic plan identifies several information technology
initiatives that could help HHS achieve some program objectives. 
However, the plan needs to more clearly discuss how HHS intends to
identify and coordinate information technology investments to support
departmentwide goals and missions.  HHS' performance plan identifies
data problems that could undermine the credibility of HHS'
performance data, but it does not state how HHS or its agencies plan
to address these data problems.  Furthermore, HHS needs to present a
comprehensive strategy for addressing Year 2000 compliance problems. 

HHS has made progress in its efforts to improve program integrity. 
In particular, HCFA has begun using the new program safeguard
authorities provided by the Congress and is taking steps to improve
its internal controls.  However, HCFA needs to more rapidly implement
its new authorities and ensure that its systems are Year 2000
compliant. 


MAJOR PERFORMANCE AND MANAGEMENT
ISSUES
=========================================================== Appendix 1

HHS' many missions affect the health and well-being of everyone in
the nation.  HHS provides health insurance for about one in every
five Americans.  Its agencies conduct medical research to expand our
knowledge of curing and preventing disease; ensure the safety of
food, drugs, and medical devices; provide health care services to
populations who might otherwise not receive care; help needy children
and families with income support; and support a range of services to
help elderly people remain independent. 

Managing these diverse and complex programs is a challenge for HHS,
and recent legislative initiatives have intensified this challenge. 
For example, to implement welfare reform under the Personal
Responsibility and Work Opportunity Act of 1996 and subsequent
legislation, HHS must give states program flexibility while
maintaining adequate oversight.  The Balanced Budget Act of 1997
(BBA) and the Health Insurance Portability and Accountability Act of
1996 (HIPAA) gave HCFA important new resources and tools for
oversight of its Medicare program, but these acts also expanded the
agency's role to include significant responsibilities HCFA had not
previously performed.  At the same time, HHS must find a timely
resolution to the Year 2000 computer problem to ensure the continued
availability of benefits and services for Medicare and Medicaid
beneficiaries.  Furthermore, the solvency of Medicare's Hospital
Insurance Trust Fund, which funds Medicare part A, is at risk.  The
Fund's trustee board projected in its 1998 annual report that the
Trust Fund will be depleted by 2008. 

Over the past several years, our reports, reports from HHS' OIG, and
the National Performance Review have documented problems with HHS'
performance and management and have recommended reforms.  This report
highlights some of the serious management challenges related to
coordination and accountability, data and information systems, and
program integrity that HHS must overcome to meet its strategic goals. 
This report also indicates how HHS has addressed some of these issues
in its 5-year strategic plan and its fiscal year 1999 annual
performance plan, which were developed in response to the Results
Act. 

SCOPE AND COMPLEXITY OF HHS
PROGRAMS CREATE COORDINATION,
OVERSIGHT, AND PERFORMANCE
MEASUREMENT CHALLENGES

Each of HHS' 11 operating agencies administers a number of programs. 
Many of these agencies have overlapping jurisdictions and concerns,
and many of their programs share like goals with programs
administered by other federal agencies.  To effectively meet these
program goals, coordination both within HHS and with other agencies
is essential.  Yet such coordination is a challenge, given the scope
and complexity of these programs.  In addition, HHS programs are
frequently administered by program partners, including state and
local governments and nongovernmental organizations that receive
block grant or categorical funding.  HHS needs to make sure that
these partners are accountable for program results, which is often a
challenge because of the flexibility states have in administering
programs and because of limited research on program effectiveness. 

HHS' strategic and performance plans provided an opportunity for HHS
to demonstrate how it will coordinate its diverse programs to achieve
common objectives.  HHS' strategic plan acknowledges the need for
coordination among the Department's operating divisions and describes
a range of approaches for improving internal coordination.  However,
while the plan also mentions the need to coordinate with state,
local, and tribal governments; contractors; and private entities that
HHS relies on as program and information partners, it does not
specify how HHS would do so. 


      MANY HHS PROGRAMS REQUIRE
      INTERNAL AND EXTERNAL
      COORDINATION
------------------------------------------------------- Appendix 1:0.1

Within HHS, a large number of programs share related objectives; many
HHS programs also share objectives with other federal agencies.  For
example, 27 different HHS programs support teen pregnancy prevention
efforts, and 8 other federal agencies--the Departments of
Agriculture, Defense, Education, Housing and Urban Development,
Justice, and Labor; the Corporation for National Service; and the
Office of National Drug Control Policy--provide funding for teen
pregnancy prevention programs.  With so many stakeholders involved,
intraagency and interagency coordination become increasingly
necessary--and complex. 

Implementing welfare reform exemplifies the coordination challenges
HHS faces.  The principal responsibility for carrying out the
legislation rests with the Administration for Children and Families
(ACF).  In addition to coordinating its own programs, which include
Temporary Assistance for Needy Families and Head Start, ACF must
coordinate with related programs in other HHS agencies, such as those
dealing with substance abuse and mental health services.  HHS must
also coordinate with the Departments of Labor and Education regarding
education, training, and employment programs that can help former
welfare recipients.  A diverse set of program partners, such as state
and local governments and nonprofit and community-based
organizations, develop and implement ACF programs and deliver the
many services they sponsor.  For example, state and county agencies,
the courts, banks, and credit bureaus help ACF implement its child
support enforcement program.  Similarly, public and private school
systems, community action agencies, and other nonprofit groups
operate Head Start programs locally. 

HHS' 1999 performance plan has a general discussion of the need for
internal and external coordination, but details about coordination
efforts were left to individual agency plans.  While some agencies'
plans carefully delineate coordination efforts, others do not provide
sufficient information to allow the Congress to assess whether their
activities will be adequately coordinated internally and externally. 
For example, it is not clear how numerous HHS programs will
coordinate efforts to accomplish the President's stated goal of
reducing smoking among young people by 50 percent by 2003--a goal HHS
adopted.  According to its strategic plan, HHS plans to achieve this
goal through research support by the National Institutes of Health;
prevention activities by the Indian Health Services (IHS), the
Centers for Disease Control and Prevention (CDC), and the Health
Resources and Services Administration; enforcement efforts by the
Food and Drug Administration (FDA); and technical assistance to
states by the Substance Abuse and Mental Health Services
Administration (SAMHSA).  However, of the agencies that were
identified as contributing to this effort, only FDA and IHS
acknowledged in their performance plans that they would coordinate
their work with the other agencies. 


      BALANCING PROGRAM
      FLEXIBILITY AND OVERSIGHT
------------------------------------------------------- Appendix 1:0.2

In administering programs that are the joint responsibility of state
governments or that involve local grantees, HHS must continually
balance program flexibility with maintaining program controls.  With
welfare reform and other recent legislation, states received greater
flexibility in designing and implementing their assistance programs
within federal guidelines.  However, at the same time, HHS is
responsible for ensuring states comply with federal laws and
regulations.  The new welfare law also gives HHS authority to impose
penalties if states fail to comply with certain requirements and
provide bonuses if states meet certain performance standards. 

The effectiveness of some HHS strategies to ensure that states comply
with federal requirements is questionable.  For example, Head Start,
which was designed to ensure maximum local autonomy, uses on-site
inspections as the primary tool for ensuring that Head Start's more
than 1,400 local grantees comply with program regulations.  Head
Start performs on-site inspections after a grantee's initial
operating year and at least once every 3 years after that.  We have
reported, however, that ACF regional office staff and outside
researchers have raised concerns about the consistency of on-site
inspections.  Although the full impact of this problem is unknown,
data based on these inspections may not be as valuable as they could
be for managing the program and making decisions about Head Start
policy.  We also found that Head Start could do more to ensure that
it accurately measures the program's actual impact by examining
program outcomes at the grantee level. 

HHS' weak oversight of programs where states share enforcement
responsibilities can fail to protect vulnerable citizens.  For
example, nursing homes that receive federal payments through Medicare
and Medicaid--which in 1997 totaled $28 billion--must comply with
certain federal requirements.  As required by statute, HCFA delegated
to the states responsibility to inspect nursing homes and certify
that they meet federal standards.  However, we have identified
problems in both inspection and enforcement.  For example, in
analyzing recent inspection and complaint information in California,
we found that nearly one in three nursing homes were cited by state
surveyors for providing care with serious or potentially
life-threatening problems.  Although the state identified serious
deficiencies, HCFA's enforcement policies were not effective in
ensuring that the deficiencies were corrected and stayed corrected. 
This is a national problem--one in nine nursing homes in the United
States was cited in its last two inspections for conditions that
harmed residents or put residents in immediate jeopardy. 

Until recently, HCFA had taken a lenient stance toward enforcing
compliance with federal standards, encouraging states to grant almost
all noncompliant homes a grace period to correct deficiencies without
penalty, regardless of past performance.  HCFA is currently
developing plans to (1) improve state inspection practices, (2)
revise oversight of state inspection agencies, (3) strengthen
enforcement actions against poorly performing nursing homes, and (4)
disseminate information to consumers and providers about nursing
homes' performance records and about best practices for certain
common care problems.  In addition, recent legislation requires the
Department of Justice to develop a mechanism that would allow nursing
homes to check whether potential employees have criminal or abusive
backgrounds. 


      DEVELOPING EFFECTIVE
      PERFORMANCE MEASURES COULD
      STRENGTHEN ACCOUNTABILITY
------------------------------------------------------- Appendix 1:0.3

Whether a program's goal is better nursing home care or better
preschool experiences for children in Head Start, HHS needs to be
able to adequately measure program performance to ensure program
accountability.  However, program scope and complexity--as well as
various methodological and resource constraints--make measuring
performance difficult.  For example, in measuring the effectiveness
of drug abuse treatment, certain factors, such as reliance on
self-reported information and insufficient client follow-up, limit
confidence in the data on treatment outcomes.  Furthermore,
comparisons of study results are complicated by differences in how
outcomes are defined and measured as well as differences in program
operations and client factors. 

HHS' strategic plan was a serious initial effort to describe goals,
objectives, and outcome measures of program performance.  However, it
could have better contributed to efforts to improve accountability by
discussing the Department's plans for future evaluations to determine
program effectiveness.  In HHS' performance plan, many agencies, such
as CDC, provided succinct and concrete statements of expected
performance, but others did not.  Most of the agencies' plans provide
at least some appropriate and quantifiable performance measures to
track progress toward performance goals.  However, HHS and its
agencies acknowledged that future performance plans should include
more outcome goals to supplement output and process goals, and they
indicated that they have begun efforts to develop them. 

HHS has made progress in working with state governments to develop
effective performance measures that promote the goals of its various
programs.  For example, the Office of Child Support Enforcement and
the states developed national goals and objectives for the child
support enforcement program.  The Maternal and Child Health Block
Grant Program has collaborated with its state partners to develop a
set of core performance measures that have now become the basis for
awarding and monitoring grants under the program.  Furthermore, HHS'
strategic plan indicates that SAMHSA is currently working with states
to develop outcome indicators for substance abuse and mental health
services and that CDC, through its categorical grant programs, is
working with states to develop health status indicators, uniform data
sets, and public health surveillance systems. 


      KEY CONTACTS
------------------------------------------------------- Appendix 1:0.4

Bernice Steinhardt, Director
Health Services Quality and Public Health
 Issues
Health, Education, and Human Services
 Division
(202) 512-7119
[email protected]

William J.  Scanlon, Director
Health Financing and Systems Issues
Health, Education, and Human Services
 Division
(202) 512-7114
[email protected]

Cynthia Fagnoni, Director
Income Security Issues
Health, Education, and Human Services
 Division
(202) 512-7215
[email protected]

Carlotta Joyner, Director
Education and Employment Issues
Health, Education, and Human Services
 Division
(202) 512-7014
[email protected]

HHS NEEDS RELIABLE AND
COMPREHENSIVE DATA AND DATA
SYSTEMS TO MANAGE PROGRAMS AND
ASSESS RESULTS

To effectively manage its extensive health insurance programs,
grant-making activities, and regulatory responsibilities, HHS must
have access to data about its programs and their effects that are
both reliable and appropriate to the task.  These data would allow
HHS to know whether or not it is accomplishing its goals and how its
programs affect the American people.  They also would provide the
Congress the information it needs to evaluate the Department's
success in meeting its goals.  However, data needed to manage and
evaluate HHS' programs are often unavailable, inaccurate, or
inconsistent.  Obtaining comparable data from programs carried out by
state and local partners is particularly difficult.  The automated
systems challenges presented by the year 2000 will simply compound
these problems; they could also put benefits and services at risk. 


      BALANCING FLEXIBILITY AND
      ACCOUNTABILITY CREATES DATA
      CHALLENGES
------------------------------------------------------- Appendix 1:0.5

To help fulfill its oversight responsibilities, HHS needs comparable
and reliable data from states.  However, state data, where available,
are often incomplete or inconsistent.  For example, HHS will use
state data to ensure states meet new welfare reform requirements,
including the 5-year time limit on receiving welfare benefits. 
However, state information on the length of time an individual has
received welfare is often unavailable or inconsistent, making it
difficult for HHS to enforce federal benefit time limits. 

HCFA faces particular challenges in collecting and publishing
consistent information to inform policymakers about Medicaid and the
new State Children's Health Insurance Program (SCHIP) created by BBA. 
Medicaid, a $160-billion federal and state program, provides health
insurance coverage for 36 million low-income people--about half of
whom are children; SCHIP was established to expand health insurance
coverage for low-income children.  States have primary responsibility
for administering these programs but share responsibility with HCFA
for data collection and management.  HCFA uses state enrollment data
to create statistical reports on Medicaid beneficiaries served, their
eligibility categories, types of services they received, and vendor
payments.  However, these data are often inaccurate and inconsistent. 
For example, while HCFA data indicate that Medicaid enrollment has
been dropping as states implement welfare reform, our review of these
data in 16 selected states found discrepancies between state and HCFA
data.  Similarly, state program variations complicate uniform
reporting for SCHIP.  For example, states do not have consistent
income standards for children's enrollment in SCHIP, and they vary in
how they count family income to determine program eligibility.  These
data problems will make it difficult to assess the impact of welfare
reform on Medicaid enrollment and the overall effectiveness of SCHIP. 

In some cases, the data HHS needs to manage its programs and assure
the Congress that it is achieving intended results are not available. 
For example, the federal government provides about $3 billion
annually to fund drug abuse prevention and treatment activities;
however, precisely determining the need for treatment services is
difficult due to limitations in national and state data.  SAMHSA's
national estimates of drug abuse treatment need are primarily derived
from the agency's National Household Survey on Drug Abuse, which,
when used for this purpose, has several limitations, including
reliance on self-reported data and the exclusion of certain groups at
high risk of drug use, such as persons who are homeless or in
prisons.  It also does not identify a large enough sample of certain
subpopulations, such as pregnant women, to adequately estimate
treatment need.  State estimates of drug treatment need are also
problematic.  Although states are required to report these estimates
in applications for federal block grant funds, our review of fiscal
year 1997 block grant applications showed that not all states
submitted such data, and some submitted incomplete or inaccurate
data. 


      LACK OF RELIABLE AND
      COMPREHENSIVE DATA MAY PUT
      INDIVIDUALS AT RISK
------------------------------------------------------- Appendix 1:0.6

The data system problems that affect HHS' ability to carry out its
oversight and regulatory responsibilities can result in risks to the
public's health.  For example, there are weaknesses in FDA's approach
for determining whether medical device manufacturers are operating
tracking systems capable of quickly locating and removing defective
devices from the market and notifying patients who use them.  These
weaknesses could result in unnecessary impairment--even death--if it
became necessary to notify patients who use a device, such as a heart
valve or pacemaker, that had been found to be defective. 

Detecting problems with pharmaceuticals is particularly difficult. 
Eighty percent of bulk pharmaceutical chemicals are imported.  To
identify foreign pharmaceutical manufacturers, plan foreign
inspections, track inspection results, and monitor enforcement
actions, FDA relies on 15 separate automated systems, most of which
do not interface.  As a result, essential foreign drug inspection
data are not readily accessible to the different FDA units that are
responsible for planning, conducting, and reviewing inspections and
taking enforcement actions against foreign manufacturers. 


      YEAR 2000 CHALLENGES PUT
      BENEFITS AND SERVICES AT
      RISK
------------------------------------------------------- Appendix 1:0.7

HCFA's automated, mission-critical systems supporting the Medicare
program are not yet Year 2000 compatible--and time is running out. 
Although HCFA recently established an internal Year 2000 organization
and hired independent contractors to assist in overseeing the Year
2000 work, we reported in September 1998 that HCFA was far behind
schedule in repairing, testing, and implementing these systems due,
in part, to the complexity and magnitude of the problem.  For
example, HCFA reported that as of June 30, 1998, less than one-third
of Medicare's 96 mission-critical systems had been fully renovated,
and none had been validated or implemented.  (See Status of HCFA's
Year 2000 Effort:  Quarterly Progress Report [Washington, D.C.:  HHS,
Aug.  15, 1998].) If not corrected, these systems could malfunction
or produce incorrect information beginning in January 2000, putting
benefits and services in jeopardy. 

To help avoid the interruption of Medicare services and payments, we
reported that HCFA needed to implement several key management
practices, including

  -- developing a risk-management process,

  -- planning for and scheduling an integrated end-to-end test of all
     key systems to ensure that Medicare-wide renovations will work
     as planned,

  -- ensuring that all external and internal systems' data exchanges
     have been identified and agreements signed between the data
     exchange partners, and

  -- accelerating the development of business continuity and
     contingency plans to allow time to ensure that they would be
     reliable and ready if needed. 

HCFA's Administrator responded that the agency would take immediate
steps to address our recommendations and would take whatever actions
are needed to ensure that there is no interruption of Medicare
services and claims payments. 

HHS also faces the possibility of massive systems failures for state
Medicaid programs--but the responsibility for systems renovations
lies with the states, not directly with HCFA.  Most states are far
from having their automated Medicaid systems ready for the year 2000. 
Of the 48 states and 3 territories that reported on the status of
their systems in July and August 1998, only 23 states had completed
more than 50 percent of their systems renovations.  HCFA has begun an
independent effort to assess states' compliance. 


      HHS PLANS COULD MORE FULLY
      ADDRESS DATA PROBLEMS
------------------------------------------------------- Appendix 1:0.8

HHS' summary overview of its performance plan discusses the
Department's reliance on its partners and stakeholders for much of
the data that will serve to assess the results of HHS programs.  The
plan also mentions problems stemming from HHS' use of existing data
systems that were established to monitor the use of resources and to
provide aggregate output data rather than to capture the outcomes of
activities.  However, most of the plan's discussions of data
limitations do not state how HHS or its agencies plan to address
these data problems, which could undermine the credibility of
performance data.  Furthermore, individual agencies did not always
provide sufficient information on data limitations, including some
data limitations we had identified in previous work, making it
difficult to assess agency progress to overcome them. 

Although HHS' strategic plan identifies several information
technology initiatives that could help HHS achieve some program
objectives, the plan does not discuss how HHS intends to identify and
coordinate information technology investments to support
departmentwide goals and missions.  Nor does the performance plan
discuss either HHS-wide information technology resources needed to
improve performance or a comprehensive strategy for addressing Year
2000 compliance problems. 


      KEY CONTACTS
------------------------------------------------------- Appendix 1:0.9

Bernice Steinhardt, Director
Health Services Quality and Public Health
 Issues
Health, Education, and Human Services
 Division
(202) 512-7119
[email protected]

William J.  Scanlon, Director
Health Financing and Systems Issues
Health, Education, and Human Services
 Division
(202) 512-7114
[email protected]

Cynthia Fagnoni, Director
Income Security Issues
Health, Education, and Human Services
 Division
(202) 512-7215
[email protected]

Joel C.  Willemssen, Director
Civil Agencies Information Systems
Accounting and Information Management
 Division
(202) 512-6408
[email protected]

PROGRAM INTEGRITY IS A CONTINUING
CHALLENGE FOR HHS

With their broad range of services, large number of grantees and
contractors, huge volume of vendor payments, and millions of
beneficiaries, HHS programs are attractive targets for fraud, waste,
abuse, and mismanagement.  Medicare is particularly vulnerable--it
pays out about $200 billion annually and is responsible for financing
health services delivered by hundreds of thousands of providers on
behalf of tens of millions of beneficiaries.  In the past, we have
designated the Medicare program as a high-risk area, and it remains
one.  HHS' OIG estimated that in fiscal year 1997, HCFA paid about
$20 billion for fee-for-service claims that did not comply with
Medicare laws and regulations.  While the Congress has given HHS new
resources and authorities to improve oversight of Medicare, HCFA's
deployment of these tools has lagged, putting on hold potential gains
expected from the Medicare Integrity Program, Medicare's prospective
payment systems, and Medicare+Choice.  Furthermore, efforts to
streamline Medicare's claims processing system have stalled, as HCFA
has focused its efforts on getting the critical data systems ready
for the year 2000.  Finally, HHS' fiscal year 1997 financial
statements had serious deficiencies. 


      HCFA SLOW TO IMPLEMENT NEW
      AUTHORITY TO PERFORM PAYMENT
      SAFEGUARD ACTIVITIES
------------------------------------------------------ Appendix 1:0.10

The Medicare Integrity Program created under HIPAA was intended to
bolster HCFA's flagging efforts to combat fraud and abuse.  The
insurance companies HCFA contracts with to process, pay, and review
Medicare claims are paid to review claims and detect fraudulent and
abusive billing practices to prevent mispayments.  The Congress
increased funding for these and other payment safeguard activities,
appropriated the funding in advance rather than annually, and
protected it from potential diversion by placing the funds in a
special fraud and abuse account.  In addition, the Congress gave
HCFA--through HHS--the authority to contract with specialists to
perform payment safeguard activities. 

However, HCFA has been slow to act.  For fiscal year 1998, HCFA did
not notify contractors of their annual safeguard funding amounts
until a third of the fiscal year had passed.  The contractors use
these funds, among other things, to hire and retain staff
knowledgeable in conducting provider audits, claims reviews, and
payment data analyses.  The delays, they believed, would make it more
difficult to complete their payment safeguard work, thus frustrating
the Medicare Integrity Program's intended purpose.  Since the time of
our review, HCFA stepped up its efforts and set contractors' fiscal
year 1999 budgets promptly.  However, HCFA has not yet implemented a
specialty program safeguard contract owing to various undecided
issues, such as which specific safeguard tasks HCFA will ask the
contractor to perform and the best geographic location for testing
the first contract.  Such a contract could be awarded in May 1999,
but the scope will be very limited and will not provide many of the
benefits initially envisioned from using a specialty contractor. 


      YEAR 2000 AND DESIGN
      CHALLENGES STALL
      IMPLEMENTATION OF MEDICARE
      PROSPECTIVE PAYMENT SYSTEMS
------------------------------------------------------ Appendix 1:0.11

Until recently, Medicare used cost reimbursement methods to pay for
services such as home health care, skilled nursing facility (SNF)
care, and hospital outpatient services.  In 1996, spending for these
services had reached double-digit spending growth.  In an effort to
encourage efficient service delivery and discourage rapid spending,
BBA mandated the design and implementation of prospective payment
systems (PPS), which pay providers--regardless of their costs--fixed,
predetermined amounts that vary according to patient need. 
Specifically, BBA requires HHS--and, by extension, HCFA--to implement
(1) a SNF PPS, which became effective in fiscal year 1998; (2) a home
health services PPS by fiscal year 1999 and an interim payment system
for these services, effective fiscal year 1997; (3) a hospital
outpatient services PPS by calendar year 1999; and (4) an inpatient
rehabilitation services PPS by fiscal year 2001. 

Challenges in developing and implementing these systems pose
significant risks: 

  -- Payment design difficulties:  Under PPS, HCFA must carefully
     monitor the accuracy of data used to develop payment levels.  It
     must also develop effective payment adjusters to account for the
     cost differences in treating patients who are more or less
     expensive than average to serve.  Under a system of fixed
     payments, inaccurate cost data and the lack of an effective
     adjuster can result in underpaying or overpaying providers;
     moreover, if providers serving expensive patients are
     financially penalized, future access for these beneficiaries is
     jeopardized.  In the case of the SNF PPS, we found that the
     methodology HCFA used to adjust rates for patient differences is
     susceptible to manipulation and could raise Medicare outlays
     rather than improve efficiency and patient care.  We also found
     that, because the data used to set the prospective rates were
     not adequately audited, overstated costs of providing services
     were built into the new rates.  Therefore, the use of these data
     may compromise the system's ability to meet the twin objectives
     of slowing spending growth while promoting the delivery of
     appropriate beneficiary care. 

  -- Implementation delays:  HCFA has announced that the home health
     PPS and outpatient PPS will be not be implemented by the 1999
     deadline because of the agency's focused efforts to ensure that
     Medicare's multiple automated systems are Year 2000 compliant. 
     The inpatient rehabilitation therapy PPS could face similar
     delays.  To the extent that delays prolong the use of the
     existing cost-based reimbursement methods or that a rushed
     implementation builds problems into a new system, Medicare will
     likely continue to make excessive payments for services in these
     areas. 


      CHALLENGES IMPLEMENTING
      MEDICARE+CHOICE THREATEN
      PROGRAM SUCCESS
------------------------------------------------------ Appendix 1:0.12

On the premise that managed care plans can save the government
unnecessary spending on Medicare services without compromising the
provision of covered benefits, BBA established Medicare+Choice.  The
program is designed to widen beneficiary and health plan
participation in Medicare managed care in several ways.  First, BBA's
guarantee of a minimum payment level can encourage health plans to
locate in areas they had not previously served.  Second, it expanded
the type of plans eligible to contract with Medicare to include--in
addition to health maintenance organizations--other models, such as
preferred provider organizations and physician-sponsored
organizations.  Third, BBA requires the development of a nationwide
campaign that would disseminate to beneficiaries useful information
on the choices available, thus promoting more effective competition
among plans. 

However, several key challenges imperil the implementation of the
Medicare+Choice program: 

  -- Payment design difficulties:  Medicare's payment rates may
     overcompensate some plans for the beneficiaries they serve
     because the rates paid for enrolled beneficiaries whose expected
     use of health services is below average are not adequately
     adjusted to reflect that lower expected use.  Although HCFA is
     currently working to develop new adjustments, as required by
     BBA, it is having difficulty collecting the encounter data
     needed to refine these adjustments. 

  -- Inadequate oversight of allowable profits:  The BBA requirement
     that HCFA audit one-third of all Medicare managed care plans
     annually could help ensure that plans do not earn excessive
     profits on their Medicare contracts.  However, studies by HHS'
     OIG and others find HCFA's current oversight in this area
     inadequate, and HCFA does not plan to begin these audits until
     2000. 

  -- Faltering plan participation:  Participation by the newly
     permitted types of managed care plans has not occurred as
     intended.  To date, only a handful of such plans have submitted
     applications to HCFA.  In addition, some of Medicare's
     traditional managed care plans are pulling out of certain areas
     or are reducing covered services and increasing beneficiaries'
     out-of-pocket costs. 

  -- Information campaign challenges:  Recognizing that consumer
     information is an essential component of a competitive market,
     BBA mandated a national information campaign with the objective
     of promoting informed plan choice.  Specifically, BBA requires
     that comparative information be available to beneficiaries
     through the Internet, through a toll-free telephone number, and
     in printed form by mail.  Organizing these efforts is an
     enormous undertaking and is a new HCFA responsibility.  The
     toll-free number and a beneficiary handbook mailing are being
     piloted in five states.  Beginning in 1999, HCFA plans to expand
     its telephone information efforts nationwide in support of an
     annual enrollment event in November.  The Congress' efforts to
     encourage the growth of managed care could be thwarted if
     beneficiaries are confused, instead of enlightened, about their
     many health care choices. 


      EFFORTS TO STREAMLINE
      MEDICARE CLAIMS PROCESSING
      SYSTEM HAVE STALLED
------------------------------------------------------ Appendix 1:0.13

A continuing challenge to HCFA's ability to maintain the integrity of
Medicare is its effort to streamline the Medicare claims processing
system.  HCFA undertook this effort to increase the efficiency of its
claims process, better manage contractors, improve customer service,
and help reduce fraud and abuse. 

The streamlining involves reducing the number of claims processing
software systems from eight to three, one of which would process only
durable medical equipment claims.  However, HCFA halted this
consolidation effort because it needed to focus resources on critical
Year 2000 work, dealing a major setback to the effort in the short
term. 


      HHS' FINANCIAL STATEMENT
      AUDITS CONTINUE TO HAVE
      PROBLEMS
------------------------------------------------------ Appendix 1:0.14

An area of HHS vulnerability on which HHS' OIG has reported is HHS'
difficulty in complying with the requirements of the Chief Financial
Officers Act, as expanded by the Government Management Reform Act of
1994.  HHS received a qualified opinion from the OIG on its fiscal
year 1997 financial statements, primarily because of (1) a lack of
adequate supporting documentation for $2.5 billion in net Medicare
accounts receivable; (2) difficulty in determining what, if any,
adjustments needed to be made to the Medicare cost settlements as
reported in the fiscal year 1997 financial statements; (3)
insufficient evidence to support $2.7 billion in grant accrual
expenses and a potential net misstatement of $386 million in grant
expenses; and (4) lack of supporting documentation for intraagency
transactions.  These serious deficiencies indicate that reliable
financial management data are not readily available to permit HHS
managers to make informed decisions.  In this regard, the OIG
reported material weaknesses in internal controls and a material
instance of noncompliance with the Federal Financial Management
Improvement Act of 1996. 

Specifically, HHS' OIG reported serious control weaknesses affecting
the reliability, confidentiality, and availability of data throughout
the Department.  It reported that the six primary accounting systems
are not electronically linked; depend on external sources, such as
Medicare contractors, for essential information; and cannot
automatically generate financial statements.  In addition, Medicare
contractors were not adequately protecting confidential personal and
medical information associated with claims.  As a result, contractor
employees could potentially browse data on individuals, search out
information on acquaintances or others, and possibly sell or
otherwise use this information for personal gain or malicious
purposes.  Furthermore, although HCFA had corrected weaknesses found
in the previous year, it was still possible to gain access to HCFA's
database and modify managed care files. 

HHS has recognized the need to protect the security of information
technology systems and the data contained in them.  Starting in 1997,
HHS began to revise security policies and guidance and required each
major operating division to develop and implement corrective action
plans to address each major weakness identified by the OIG.  However,
due to its decision to focus on Year 2000 modifications, HCFA will
probably not address many of these electronic data processing control
weaknesses in the near future.  Therefore, concerns related to the
integrity of claims paid and the confidentiality of medical records
will continue. 

In addition, the fiscal year 1997 financial statement audit again
reported HCFA's inadequate oversight of the Medicare program as a
material weakness--one that hampers HHS' fiduciary responsibilities. 
For example, HCFA had not developed its own process for estimating
the national error rate for improper Medicare fee-for-service
payments.  For fiscal year 1997, HHS' Inspector General estimated
that about 11 percent of all Medicare fee-for-service payments for
claims, or about $20 billion, did not comply with Medicare laws and
regulations.  Similarly, we reported in our first audit of the
federal government that problems exist in estimating improper
payments for major programs, and among these were programs
administered by HHS. 

While HHS' strategic plan recognizes the importance of improving the
Department's financial management information, it does not specify
the corrective actions and timetables needed to obtain an unqualified
or clean opinion on its financial statements.  When financial
management issues are closely related to accomplishing an agency's
mission, the agency's performance plan should include goals related
to improving the reliability and timeliness of financial data.  HCFA
and IHS included such goals in their plans.  The plans of other
operating divisions--such as ACF, whose fiscal year 1997 financial
statement audit found several financial accountability
deficiencies--could also have benefited from financial-related goals. 


      KEY CONTACTS
------------------------------------------------------ Appendix 1:0.15

William J.  Scanlon, Director
Health Financing and Systems Issues
Health, Education, and Human Services
 Division
(202) 512-7114
[email protected]

Bernice Steinhardt, Director
Health Services Quality and Public Health
 Issues
Health, Education, and Human Services
 Division
(202) 512-7119
[email protected]

Cynthia Fagnoni, Director
Income Security Issues
Health, Education, and Human Services
 Division
(202) 512-7215
[email protected]

Gloria L.  Jarmon, Director
Health, Education, and Human Services
 Accounting and Financial Management
Accounting and Information Management
 Division
(202) 512-4476
[email protected]

Joel C.  Willemssen, Director
Civil Agencies Information Systems
Accounting and Information Management
 Division
(202) 512-6408
[email protected]


RELATED GAO PRODUCTS
=========================================================== Appendix 2

COORDINATION, OVERSIGHT, AND
PERFORMANCE MEASUREMENT

Teen Pregnancy:  State and Federal Efforts to Implement Prevention
Programs and Measure Their Effectiveness (GAO/HEHS-99-4, Nov.  30,
1998). 

California Nursing Homes:  Care Problems Persist Despite Federal and
State Oversight (GAO/HEHS-98-202, July 27, 1998). 

Head Start:  Challenges in Monitoring Program Quality and
Demonstrating Results (GAO/HEHS-98-186, June 30, 1998). 

Grant Programs:  Design Features Shape Flexibility, Accountability,
and Performance Information (GAO/GGD-98-137, June 22, 1998). 

The Results Act:  Observations on the Department of Health and Human
Services' Fiscal Year 1999 Annual Performance Plan (GAO/HEHS-98-180R,
June 17, 1998). 

Drug Abuse:  Research Shows Treatment Is Effective, but Benefits May
Be Overstated (GAO/HEHS-98-72, Mar.  27, 1998). 

Department of Health and Human Services:  Strategic Planning and
Accountability Challenges (GAO/T-HEHS-98-96, Feb.  26, 1998). 

The Results Act:  Observations on the Department of Health and Human
Services' April 1997 Draft Strategic Plan (GAO/HEHS-97-173R, July 11,
1997). 

Child Support Enforcement:  Reorienting Management Toward Achieving
Better Program Results (GAO/HEHS/GGD-97-14, Oct.  25, 1996). 

DATA AND DATA SYSTEMS

Year 2000 Computing Crisis:  Readiness of State Automated Systems to
Support Federal Welfare Programs (GAO/AIMD-99-28, Nov.  6, 1998). 

Medicare Computer Systems:  Year 2000 Challenges Put Benefits and
Services in Jeopardy (GAO/AIMD-98-284, Sept.  28, 1998). 

Medical Devices:  FDA Can Improve Oversight of Tracking and Recall
Systems (GAO/HEHS-98-211, Sept.  24, 1998). 

Information Security:  Serious Weaknesses Place Critical Federal
Operations and Assets at Risk (GAO/AIMD-98-92, Sept.  23, 1998). 

Drug Abuse Treatment:  Data Limitations Affect the Accuracy of
National and State Estimates of Need (GAO/HEHS-98-229, Sept.  15,
1998). 

Welfare Reform:  States Are Restructuring Programs to Reduce Welfare
Dependence (GAO/HEHS-98-109, June 18, 1998). 

Food and Drug Administration:  Improvements Needed in the Foreign
Drug Inspection Program (GAO/HEHS-98-21, Mar.  17, 1998). 

Blood Supply:  FDA Oversight and Remaining Issues of Safety
(GAO/PEMD-97-1, Feb.  25, 1997). 

PROGRAM INTEGRITY

Medicare Managed Care:  Payment Rates, Local Fee-for-Service
Spending, and Other Factors Affect Plans' Benefit Packages
(GAO/HEHS-99-9R, Oct.  9, 1998). 

Financial Management:  Federal Financial Management Improvement Act
Results for Fiscal Year 1997 (GAO/AIMD-98-268, Sept.  30, 1998). 

Balanced Budget Act:  Implementation of Key Medicare Mandates Must
Evolve to Fulfill Congressional Objectives (GAO/T-HEHS-98-214, July
16, 1998). 

Medicare:  Health Care Fraud and Abuse Control Program Financial
Report for Fiscal Year 1997 (GAO/AIMD-98-157, June 1, 1998). 

Medicare:  HCFA's Use of Anti-Fraud-and-Abuse Funding and Authorities
(GAO/HEHS-98-160, June 1, 1998). 

Medicare Managed Care:  Information Standards Would Help
Beneficiaries Make More Informed Health Plan Choices
(GAO/T-HEHS-98-162, May 6, 1998). 

Financial Audit:  1997 Consolidated Financial Statements of the
United States Government (GAO/AIMD-98-127, Mar.  31, 1998). 

Medicare:  Recent Legislation to Minimize Fraud and Abuse Requires
Effective Implementation (GAO/T-HEHS-98-9, Oct.  9, 1997). 

Medicare HMOs:  HCFA Could Promptly Reduce Excess Payments by
Improving Accuracy of County Payment Rates (GAO/T-HEHS-97-78, Feb. 
25, 1997). 


PERFORMANCE AND ACCOUNTABILITY
SERIES
=========================================================== Appendix 3

Major Management Challenges and Program Risks:  A Governmentwide
Perspective (GAO/OCG-99-1)

Major Management Challenges and Program Risks:  Department of
Agriculture (GAO/OCG-99-2)

Major Management Challenges and Program Risks:  Department of
Commerce (GAO/OCG-99-3)

Major Management Challenges and Program Risks:  Department of Defense
(GAO/OCG-99-4)

Major Management Challenges and Program Risks:  Department of
Education (GAO/OCG-99-5)

Major Management Challenges and Program Risks:  Department of Energy
(GAO/OCG-99-6)

Major Management Challenges and Program Risks:  Department of Health
and Human Services (GAO/OCG-99-7)

Major Management Challenges and Program Risks:  Department of Housing
and Urban Development (GAO/OCG-99-8)

Major Management Challenges and Program Risks:  Department of the
Interior (GAO/OCG-99-9)

Major Management Challenges and Program Risks:  Department of Justice
(GAO/OCG-99-10)

Major Management Challenges and Program Risks:  Department of Labor
(GAO/OCG-99-11)

Major Management Challenges and Program Risks:  Department of State
(GAO/OCG-99-12)

Major Management Challenges and Program Risks:  Department of
Transportation (GAO/OCG-99-13)

Major Management Challenges and Program Risks:  Department of the
Treasury (GAO/OCG-99-14)

Major Management Challenges and Program Risks:  Department of
Veterans Affairs (GAO/OCG-99-15)

Major Management Challenges and Program Risks:  Agency for
International Development (GAO/OCG-99-16)

Major Management Challenges and Program Risks:  Environmental
Protection Agency (GAO/OCG-99-17)

Major Management Challenges and Program Risks:  National Aeronautics
and Space Administration (GAO/OCG-99-18)

Major Management Challenges and Program Risks:  Nuclear Regulatory
Commission (GAO/OCG-99-19)

Major Management Challenges and Program Risks:  Social Security
Administration (GAO/OCG-99-20)

Major Management Challenges and Program Risks:  U.S.  Postal Service
(GAO/OCG-99-21)

High-Risk Series:  An Update (GAO/HR-99-1)


The entire series of 21 performance and accountability reports and
the high-risk series update can be ordered by using the order number
GAO/OCG-99-22SET. 


*** End of document. ***