Health Care Access: Programs for Underserved Populations Could Be
Improved (Testimony, 03/23/2000, GAO/T-HEHS-00-81).

Pursuant to a congressional request, GAO discussed the effectiveness of
the Health Resources and Services Administration's (HRSA) two safety-net
programs--the Community and Migrant Health Center program and the
National Health Service Corps--to improve access to medically
underserved populations.

GAO noted that: (1) both the health centers and the Corps are important
safety-net providers to the nation's vulnerable populations, but GAO
believes certain improvements would enhance the effectiveness of these
programs; (2) most health centers continue to be able to serve
vulnerable populations, even though a number of significant changes have
occurred in the health care environment; (3) HRSA has helped centers
respond to developments such as the growing number of uninsured and
Medicaid's increased use of managed care by encouraging centers to form
networks and participate in managed care; (4) HRSA could increase its
effectiveness, however, by establishing a systematic "best practices"
program to allow centers to learn from one another and by improving the
completeness and accuracy of its data--especially financial--that are
used to monitor centers; (5) the Health Care Financing Administration,
which administers the Medicaid program, could help ensure health
centers' continued ability to serve Medicaid beneficiaries and the
uninsured by monitoring state Medicaid programs' compliance with federal
requirements for reimbursing centers; (6) since its reauthorization in
1990, the Corps has expanded and now provides thousands of health care
providers to underserved areas; (7) however, it, too, could be more
effective; (8) a shift of resources could help to provide more loan
repayments; and (9) also needed are an improved system to identify and
measure areas' need for Corps providers, a better placement process, and
coordination with other federal and state efforts to place providers in
areas that need them.

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

 REPORTNUM:  T-HEHS-00-81
     TITLE:  Health Care Access: Programs for Underserved Populations
	     Could Be Improved
      DATE:  03/23/2000
   SUBJECT:  Health insurance
	     Health care programs
	     Disadvantaged persons
	     Community health services
	     Managed health care
	     Federal/state relations
	     Federal aid programs
	     Health centers
	     Health services administration
IDENTIFIER:  HHS Community and Migrant Health Centers Program
	     HHS Consolidated Health Centers Program
	     Medicaid Program
	     Medicare Program
	     State Children's Health Insurance Program
	     HRSA Integrated Services Development Initiative
	     HRSA Uniform Data System
	     USIA J-1 Visa Program
	     HRSA Primary Care Effectiveness Review

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   * For Release on Delivery
     Expected at 9:15 a.m.

Thursday, March 23, 2000

GAO/T-HEHS-00-81

HEALTH CARE ACCESS

Programs for Underserved Populations Could Be Improved

        Statement of Janet Heinrich, Associate Director

Health Financing and Public Health Issues

Health, Education, and Human Services Division

Testimony

Before the Subcommittee on Public Health and Safety, Committee on Health,
Education, Labor and Pensions, U.S. Senate

United States General Accounting Office

GAO

Health Care Access: Programs for Underserved Populations Could Be Improved

Mr. Chairman and Members of the Subcommittee:

We are pleased to be here today as you discuss federal safety-net programs
intended to improve access to medically underserved populations. As you
know, many Americans face barriers to obtaining primary health care. These
Americans may live in isolated rural areas or inner-city neighborhoods and
lack access to health services or a sufficient number of health care
providers. In addition, an increasing number of people lack health
insurance. Research shows that people in these situations use less care,
often forego seeking care when ill, or travel long distances to get care.

My statement today will focus on two safety-net programs administered by the
Department of Health and Human Services' (HHS) Health Resources and Services
Administration (HRSA): the Community and Migrant Health Center program and
the National Health Service Corps (Corps). Community and Migrant Health
Centers (health centers) were authorized about 35 years ago to increase the
availability of primary and preventive health care services for low-income
people living in medically underserved areas. In some communities, these
centers may be the only primary care provider available to vulnerable
populations, such as minorities and uninsured families. Health centers rely
on public and private funding sources, including federal, state, and local
governments; foundation grants; and payments for services from Medicaid,
Medicare, private insurance, and patients. Fiscal year 2000 appropriations
for the Consolidated Health Centers program totaled over $1 billion. The
National Health Service Corps provides some of the health professionals who
work in the centers and other sites in communities where there is a shortage
of providers. The Corps offers scholarships and educational loan repayments
for health care professionals who, in turn, agree to serve for specific
periods in communities that have a shortage of health professionals. Since
its establishment in 1970, the Corps has placed thousands of health care
providers, including physicians, nurses, and dentists, in such communities.
The information presented today is based on our report on health centers,
being issued today at the request of you and Senator Jeffords, and on
several reports we have issued since 1995 related to Corps operations and
other efforts to improve access to care. We conducted follow-up work to
update the findings and recommendations contained in the earlier reports.

In brief, we found that both the health centers and the Corps are important
safety-net providers to our nation's vulnerable populations, but we believe
certain improvements would enhance the effectiveness of these programs. Most
health centers continue to be able to serve vulnerable populations, even
though a number of significant changes have occurred in the health care
environment. HRSA has helped centers respond to developments such as the
growing number of uninsured and Medicaid's increased use of managed care by
encouraging centers to form networks and participate in managed care. HRSA
could increase its effectiveness, however, by establishing a systematic
"best practices" program to allow centers to learn from one another and by
improving the completeness and accuracy of its data-especially
financial-that are used to monitor centers. The Health Care Financing
Administration (HCFA), which administers the Medicaid program, could help
ensure health centers' continued ability to serve Medicaid beneficiaries and
the uninsured by monitoring state Medicaid programs' compliance with federal
requirements for reimbursing centers.

Since its reauthorization in 1990, the National Health Service Corps has
expanded and now provides thousands of health care providers to underserved
areas. However, it, too, could be more effective. For example, a shift of
resources could help to provide more loan repayments. Also needed are an
improved system to identify and measure areas' need for Corps providers, a
better placement process, and coordination with other federal and state
efforts to place providers in areas that need them.

Health Centers Have Been a Relatively Stable Source of Care for Underserved
People in Urban and Rural Areas

Most Health Centers Stay in Business,Operating More Sites and Serving More
Patients

According to HRSA, about 40 percent of all health centers are doing well,
maintaining sufficient staff capacity and serving a growing number of
patients. About 50 percent are considered viable but are experiencing some
operational problems. The remaining 10 percent are struggling to survive,
and they typically have major financial problems, such as a large deficit,
vacancies on their management team, or significant losses or turnover of
core health providers. Each year, a small proportion of centers-about 2
percent-actually lose federal funding, typically due to poor financial
performance. Centers' degree of success is not necessarily constant. Health
centers that excel for a few years sometimes develop problems, and some
having problems have improved their situation and become more successful.

Community and migrant health centers provide mostly primary health care,
averaging four encounters per patient per year; they are also required to
provide services that enable center users to gain access to care, such as
transportation and translation services. We found that the average number of
enabling service encounters reported by health centers dropped from 1996 to
1998, and health centers in some states have reported eliminating or
reducing transportation, education, and counseling services.

Health Center Patients Are Predominantly From Vulnerable Populations, and
Many Lack Health Insurance

Reflecting the national growth in the uninsured, the number of uninsured
people receiving care at health centers increased 10 percent between 1996
and 1998, with the share of center patients lacking health insurance
reaching 40 percent. The proportion of Medicaid patients declined slightly.
Medicaid was, however, the largest source of coverage for health center
users with health insurance; about one-third of health center users in 1998
were Medicaid beneficiaries.

In 1998, health centers reported revenues of almost $3 billion. Medicaid was
the largest funding source, representing about 35 percent of the total.
HRSA's health center grants were the second largest source, representing 23
percent of the total. (See fig. 2.) The proportion of revenue that comes
from Medicaid has increased gradually, while the proportion of health center
revenue that comes from federal grant funding has steadily declined.

Medicaid Has Become the Largest Source of Health Center Revenue

In response to the increase in the uninsured and other challenges facing
health centers, the Congress passed legislation to substantially increase
the health center program budget for the last 2 fiscal years. Federal
funding for health centers increased by $100 million in fiscal year 1999 and
another $99 million in fiscal year 2000. Over 80 percent of the existing
health centers received an increase in funding in 1999, and HRSA also
allocated funds for 19 new community and migrant health centers and gave
existing centers funds to open 27 new sites.

Growth of Medicaid Managed Care and Changes in Payment Policies Can Affect
Health Centers

and territories. Our analysis also indicates that the effect of Medicaid
managed care on health center revenue varies by state and individual center,
reflecting differences in payment practices among states and managed care
organizations. According to directors of primary care associations in
several states with Medicaid managed care programs, the implementation of
managed care has resulted in the loss of Medicaid revenues at some health
centers.

Almost all state and territorial Medicaid programs serve at least some
beneficiaries through managed care plans. Moreover, between 1991 and 1998,
the proportion of Medicaid beneficiaries enrolled in managed care increased
from 9.5 percent to 54 percent. Under waiver authority of section 1115 or
1915(b) of the Social Security Act, states may require people eligible for
Medicaid to enroll in a managed care plan. In addition, section 4701 of the
Balanced Budget Act of 1997 (BBA) gave states the ability to implement
mandatory managed care programs without obtaining a special waiver from HCFA
if they meet certain requirements. In these programs, states typically pay
managed care organizations a fixed monthly capitation fee to provide all
covered services needed by enrolled beneficiaries. Therefore, to serve
Medicaid beneficiaries in managed care, health centers must either contract
with a managed care organization to provide services to its enrollees or
form their own managed care organization.

Health center revenue may also be affected by states' implementation of
statutory Medicaid requirements for reimbursing community and migrant health
centers and other federally qualified health centers, as well as waivers of
those requirements given to states. Beginning in 1989, Medicaid was required
to reimburse federally qualified health centers at 100 percent of their
reasonable costs. In September 1999, 15 states had been exempted, under
their section 1115 waivers, from the requirement to provide 100-percent
cost-based reimbursement for these centers. The terms and conditions of a
majority of such waivers included a provision that centers be reimbursed on
a cost-related or risk-adjusted basis. Section 4712(a) of BBA allowed all
states to gradually reduce their reimbursement levels for health centers
through fiscal year 2004; section 603 of the Medicare, Medicaid and State
Children's Health Insurance Program Balanced Budget Refinement Act of 1999
modified these provisions, slowing the phase-down.

Few states have made long-term decisions about how to pay health centers
that provide services to Medicaid patients in light of the changes in the
federal requirement for cost-based reimbursement. Five states have passed
legislation ensuring 100-percent payment, 25 other states will continue
100-percent reimbursement for at least fiscal year 2000, but most have not
made any decisions about what payment method they will use in the long term.
Seven states have already reduced their reimbursement to the BBA floor of 95
percent of costs.

If a managed care organization payment for a Medicaid service is
insufficient to meet a health center's costs, states are required under
section 4712(b) of BBA to make up a portion of the difference with a
supplemental, or "wraparound," payment. The payment amount, when combined
with the managed care payment, should equal the statutorily required
percentage of costs-for example, 95 percent in fiscal year 2000. Some states
with large Medicaid enrollments, including California and Florida, delayed
giving health centers the required supplemental payments established by BBA
until HCFA intervened or until health centers filed suit.

Timely Responses to Changes in the Health Care Environment Contribute to
Centers' Success

Increasingly, health centers are trying to compete for patients and improve
their operations by forming partnerships or networks with other health care
providers. Networks can enable centers to share expertise and resources-such
as information systems or fiscal operations-control costs, or improve the
quality of clinical services. For example, a Florida network consisting of
four health centers and one homeless health center integrates
administrative, fiscal, information system, clinical, and program planning
and development services. Participating centers have improved their
efficiency by sharing four major managerial positions and a centralized
automated information system.

Effectively addressing the growth of managed care is another factor critical
to some health centers' success. While some health centers participate in
managed care by contracting with managed care organizations, others have
formed their own managed care plans, either individually or in networks with
other health centers or other health care providers. As of June 1999, 25
health center managed care plans in 18 states served almost 959,900 members.

HRSA officials and others knowledgeable about health centers believe that
the more successful centers know how to attract patients with diverse
payment sources, including those with private and public insurance. These
centers also pursue a wide variety of revenue sources-such as private
donations, foundation grants, or local government funding-to pay for
services and facilities. Good billing, collection, and reporting systems
help to maximize collections from these various revenue sources.

Many health centers are also seeking accreditation through the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO), believing
this will improve their competitiveness. HRSA is encouraging all centers to
take this action. As of August 1999, 124 health centers had received
accreditation. Health center directors and HRSA officials believe that
preparing for and going through the accreditation process are valuable
experiences because they can improve the quality of services and staff
commitment to high standards. Some center managers also believe that
achieving accreditation gets them recognition from other providers as well
as consumers and that it will improve their ability to negotiate favorable
contracts and rates with managed care organizations and other providers.
However, evidence of whether JCAHO accreditation improves health centers'
bargaining position is just beginning to be reported.

Poor Management Has Contributed to Some Health Centers' Problems

Most of the health centers that we reviewed and that were defunded or
identified by HRSA as having serious operational problems had management
that demonstrated a lack of understanding of their centers' business
operations. In general, the centers operated inefficiently, resulting in
expenses that exceeded income. When faced with difficult financial
situations, the managers of these centers did not take the necessary actions
to control expenditures and restore their center's financial viability. In
some cases, the center's board had not provided active oversight, including
exercising its responsibility to replace the health center leadership.

Some HRSA Strategies to Help Health Centers Show Promise; Others Need
Improvement

To help health centers strategically respond to changes in the health care
environment, HRSA has provided grants to states' primary care associations
to conduct marketplace analyses that help identify areas where new or
expanded services would improve access. For example, a marketplace analysis
in Colorado found that one area had no doctors accepting Medicaid patients
or offering care on a sliding-fee basis. This led to an existing health
center grantee using HRSA funding to open a new site in the underserved area
in 1999.

To encourage health center participation in managed care, HRSA's Integrated
Services Development Initiative gives health centers grants to help them
develop comprehensive integrated delivery systems and practice management
networks. HRSA also provides training, technical assistance, and financial
support to help health centers participate in managed care. As health
centers enter into managed care contracts, they need to know their costs,
understand their competition, and carefully consider how much financial risk
they can assume. While some health center managers have found HRSA's courses
on managed care helpful, others told us that HRSA's training on negotiating
managed care contracts could have been more timely and provided more
specific information to help them negotiate contracts.

In addition, HRSA does not have a systematic mechanism to allow all health
centers to share information and learn from one another. Consequently, many
centers work on developing solutions to the same problems for which other
centers have already devised successful strategies. For example, we learned
of two health centers that independently developed a productivity
measurement system. Therefore, we recommended in our report, issued today,
that HRSA establish a best practices program to facilitate health centers'
sharing of information.

HCFA also has responsibilities for helping to ensure that vulnerable
populations have access to health care services. One of HCFA's
responsibilities is ensuring that state Medicaid programs properly reimburse
health centers. If states do not comply with federal payment provisions,
health centers' ability to serve both Medicaid patients and uninsured people
can be impaired. Over the years, HCFA has sent state Medicaid agencies
instructions on how to implement health center payment changes, such as
those established by BBA. HCFA has not routinely reviewed state operations
to determine their compliance with the laws affecting health centers;
instead, it typically responds to issues brought to its attention. In the
report we issued today, we also recommended that HCFA monitor state Medicaid
programs' compliance with federal payment requirements and intervene when
states do not meet their financial obligations to health centers.

HRSA Monitors Health Center Performance, but Timely Problem Identification
and Intervention Are Difficult and Data Collection Needs Improvement

To understand how health centers are operating and to evaluate their overall
performance, HRSA each year collects administrative, demographic, financial,
and utilization data from each center through its Uniform Data System (UDS).
While UDS gathers some useful information, it also has weaknesses and
limitations. Instructions to centers have not always been clear, data
editing and cleaning processes have not always worked well, and some centers
have failed to report certain data elements or have reported them very late,
even though complete and accurate reporting is a condition of receiving a
HRSA grant.

UDS also has limitations for monitoring and evaluating performance. The
financial data in UDS cannot provide an accurate indication of an individual
center's financial status because costs are reported on an accrual basis,
while revenues are reported on a cash basis. This makes it difficult to
estimate the extent to which centers' revenues cover costs. The required
independent financial audit is perhaps the best source of accurate
information on a health centers' fiscal health, but there are delays in
HRSA's receipt of the financial audits. HRSA officials have taken steps to
improve UDS and the collection of performance information. Our report
recommends that HRSA further improve the quality of UDS data, enforce the
requirement that every grantee report complete and accurate data, and use
more accurate and timely financial data to monitor performance.

Another method HRSA uses to monitor health center performance is its Primary
Care Effectiveness Review. These reviews, which include on-site visits, are
a mandatory part of the grant renewal process, which occurs every 3 to 5
years. Health centers with identified problems are expected to take
corrective actions before receiving additional grant funding. When
necessary, HRSA sends consultants to help centers develop a financial
recovery or action plan that can help them solve their financial or
operational problems. However, sometimes HRSA's interventions have been too
late to make a difference. The agency often goes through a lengthy process
before deciding whether to continue funding a particular health center or
pursue other alternatives for providing primary care services in the area,
such as a merger with another grantee.

For centers seeking JCAHO accreditation, HRSA has been able to obtain
information from the JCAHO survey to help monitor centers, but the JCAHO
process does not provide HRSA with all the information it needs on health
centers' fiscal, information system, and other operations. HRSA currently
supplements the JCAHO survey with its own fiscal and information system
review protocols.

Corps Reauthorization Provides Opportunities for Improvements

Loan Repayment Program Has Favorable Costs and Benefits

We found that, for several reasons, the loan repayment program is generally
the better approach to provide health care professionals to shortage areas:

   * The loan repayment program costs less. On average, a year of service by
     a physician under the scholarship program costs the federal government
     over $43,000 compared with less than $25,000 under the loan repayment
     program. A major reason for this difference is the time value of
     money-7 or more years can elapse between when a physician receives
     scholarship assistance and begins to practice in an underserved area.
     In the loan repayment program, however, the federal government does not
     pay until after the service has begun.
   * Loan repayment recipients are more likely to complete their service
     obligations. This is not surprising when one considers that scholarship
     recipients enter into their contracts up to 7 or more years before
     beginning their service obligation, during which time their
     professional interests and personal circumstances may change. Twelve
     percent of scholarship recipients breached their contract to serve
     between 1980 and 1999, compared with about 3 percent of loan repayment
     recipients since that program began.
   * Loan repayment recipients are more likely to continue practicing in the
     underserved community after completing their obligation. How long
     providers remain is not clear, because the Corps does not have a
     tracking system in place. However, we analyzed data for calendar years
     1991 through 1993 and found that 48 percent of loan repayment
     recipients were still at the same site 1 year after fulfilling their
     obligation, compared to 27 percent for scholarship recipients. Again,
     this finding is not surprising. Because loan repayment recipients do
     not commit to service until after they have completed training, they
     are more likely to know what they want to do and where they want to
     live or practice at the time they make the commitment.

For these reasons, we suggest now-as we did in our 1995 report on the
Corps-that the Congress consider modifying the current requirement that
scholarships receive at least 40 percent of the funding. Besides being
generally less costly and having favorable benefits, the loan repayment
program allows the Corps to respond more quickly to changing needs. If
demand suddenly increases for a certain type of health professional, the
Corps can recruit graduates right away through loan repayments. By contrast,
giving a scholarship means waiting for years for the person to complete
training.

This is not to say that the scholarship program should be eliminated.
Because scholarship recipients have fewer choices of where they can fulfill
their service obligation, they could be directed to the neediest sites.
However, our work indicates this advantage has not worked out in practice.
For Corps providers beginning practice in 1993-94, we found no significant
difference, on average, between scholarship and loan payment recipients in
the priority of their service location. This suggests that the scholarship
program should be tightened so that it focuses on those areas with critical
needs that cannot be met through loan repayment. In this regard, one way to
increase the number of providers in high priority areas might be to reduce
the number of sites that scholarship recipients can choose from, so that the
focus of scholarships is clearly on the neediest sites. While placing
greater restrictions on service locations could potentially reduce interest
in the scholarship program, the program currently has almost seven
applicants for every scholarship-suggesting the interest level is high
enough to allow for some tightening in the program's conditions. If that
should fail, additional incentives to get providers to the neediest areas
might need to be explored.

Current System for Identifying Need Could

Be Improved

Over the past 5 years, we have identified and reported on a number of
problems with HHS' process for determining whether an area is a HPSA. In
addition to problems with the timeliness and quality of the data used, we
found that HHS' current approach does not count some providers already
working in shortage areas. For example, it does not count nonphysicians
providing primary care, such as nurse practitioners, and it does not count
Corps providers already practicing in the shortage area. As a result, the
current HPSA system tends to overstate the need for more providers, limiting
HHS' ability to identify the universe of need and prioritize areas.

Recognizing these flaws, HHS has been working on ways to improve the
designation of HPSAs, but the problems have not yet been resolved. After
studying the changes needed to improve its HPSA designation system for most
of the 1990s, HHS published a proposed rule in the Federal Register in
September 1998. This proposal included provisions to update the designations
regularly and count nonphysician practitioners. The proposed rule generated
a large volume of comments and a high level of concern about its potential
effect. In particular, people in some areas were concerned that the new
criteria would result in their losing their HPSA designations. In June 1999,
HHS announced that it would conduct further analyses before proceeding.

The controversy surrounding proposed modifications to the HPSA designation
system may be due, in large part, to its use by other programs. Originally,
the system was only used to identify an area that could request providers
from the Corps. Today, many federal and state programs-including efforts
unaffiliated with HHS-use the HPSA designation in considering program
eligibility. These areas want the HPSA designation in order to be eligible
for other programs such as a 10-percent bonus on Medicare payments or
cost-based reimbursement under the Rural Health Clinic program.

Current Placement Process Could Be Improved

One question we have examined is whether providers are being placed in as
many needy areas as possible. In analyzing placements for 1993, we found
that at least 22 percent of shortage areas receiving Corps providers
received more providers than needed to increase their provider-to-population
ratio to the point that their HPSA designation could be removed, while 65
percent of shortage areas with Corps-approved vacancies did not receive any
providers. Of these latter locations, 143 had unsuccessfully requested a
Corps provider for 3 years or more. The Corps has subsequently made
improvements in its procedures and has substantially cut the number of HPSAs
not receiving providers. However, that number is still above 380, and some
HPSAs can still receive more than enough providers to remove their shortage
designation.

HHS officials have said that in making placements, they need to weigh-in
addition to assisting as many shortage areas as possible-the viability of
the site and the chance that a provider might stay beyond the period of
obligated service. However, because the sites that are on the vacancy list
have to meet Corps requirements for infrastructure and salary, viability
should not be an issue for those locations. And while we agree that
retention is a laudable goal, the effect of the Corps' current practice is
unknown because the Corps does not track long-term retention. We suggest
that the Congress consider clarifying the extent to which the program should
try to meet the minimum needs of as many shortage areas as possible and the
extent to which additional placements should be allowed to try to encourage
provider retention.

Placement Efforts Need Better Coordination With Waivers for J-1 Visa
Physicians

Waiver placements have become so numerous that they now surpass Corps
physicians. In September 1999, over 2,000 physicians had waivers and were
practicing in or contracted to practice in underserved areas, compared with
1,356 Corps physicians. The number of waiver physicians is now large enough
to total over one-third of the full-time primary care physicians needed to
eliminate HPSA designations nationwide.

Although coordinating Corps placements and waiver placements has the obvious
advantage of addressing the needs of as many underserved locations as
possible, it is not occurring. As a result, some areas have ended up with
more than enough physicians to remove their shortage designations, while
needs in other areas have gone unfilled. There are two main reasons for the
problem:

   * HHS does not support the waiver approach as a sound way to address
     underservice needs in the United States. The agency's position is that
     physicians should return home after completing their medical training
     to make their knowledge and skills available to their home countries.
     As a result, although the states and other federal agencies are using
     waivers to address underservice, HHS does not have a system to take
     these placements into account in determining where to put Corps
     physicians.
   * This sizeable domestic placement effort is rudderless. Even among those
     states and agencies using the waiver approach, no agency has
     responsibility for ensuring that placement efforts are coordinated.
     While some informal coordination may occur, it remains a fragmented
     effort with no overall program accountability.

As the Congress considers reauthorizing the Corps, it has the opportunity to
address these issues. As we previously reported, we believe that the
prospects for coordination could be enhanced by action in two areas. First,
clarify how the use of waivers for these physicians fits into the overall
federal government strategy for addressing underservice. This should include
determining the size of the J-1 visa waiver program and establishing how it
should be coordinated with other federal programs. Second, designate
leadership responsibility for managing the J-1 visa activity for physicians
as a distinct program.

Concluding Observations

GAO Contacts and Acknowledgments

For future contacts regarding this testimony, please call Janet Heinrich,
Associate Director, Health Financing and Public Health Issues, at (202)
512-7119 or Helene Toiv, Assistant Director, Health Financing and Public
Health Issues, at (202) 512-7162. Other individuals who made key
contributions include Renalyn Cuadro, Anne Dievler, Brenda James, Frank
Pasquier, and Kim Yamane.

Related GAO Reports

Community Health Centers: Adapting to Changing Health Care Environment Key
to Continued Success, (GAO/HEHS-00-39, Mar. 10, 2000)

Physician Shortage Areas: Medicare Incentive Payments Not an Effective
Approach to Improve Access (GAO/HEHS-99-36, Feb. 26, 1999)

Health Care Access: Opportunities to Target Program and Improve
Accountability (GAO/T-HEHS-97-204, Sept. 11, 1997)

Foreign Physicians: Exchange Visitor Program Becoming Major Route to
Practicing in U.S. Underserved Areas, (GAO/HEHS-97-26, Dec. 30, 1996)

National Health Service Corps: Opportunities to Stretch Scarce Dollars and
Improve Provider Placement, (GAO/HEHS-96-28, Nov. 24, 1995)

Health Care Shortage Areas: Designations Not a Useful Tool for Directing
Resources to the Underserved, (GAO/HEHS-95-200, Sept. 8, 1995)

(201036)

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