Department of Health and Human Services: Strategic Planning and
Accountability Challenges (Testimony, 02/26/98, GAO/T-HEHS-98-96).

GAO discussed the challenges the Department of Health and Human Services
(HHS) faces in carrying out its mission effectively and cost-efficiently
and in improving its accountability for the results of its efforts and
its stewardship of taxpayer dollars.

GAO noted that: (1) considering the breadth and complexity of HHS'
responsibilities, the size of its budget, and the importance of its
programs, it is essential that HHS successfully and efficiently fulfill
its mission; (2) HHS is committed to carrying out its programs
efficiently, but problems have often been identified with HHS programs;
(3) HHS deserves credit for its progress in complying with the
requirements of the Government Performance and Results Act; (4) the next
critical stage in improving HHS' accountability for the public's
investment in its programs will be to move from its strategic planning
efforts to efficiently accomplishing its goals and objectives; and (5)
successfully implementing HHS' plans will require vigilance by HHS and
its agencies as well as continued congressional oversight.

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

 REPORTNUM:  T-HEHS-98-96
     TITLE:  Department of Health and Human Services: Strategic Planning 
             and Accountability Challenges
      DATE:  02/26/98
   SUBJECT:  Program evaluation
             Strategic planning
             Internal controls
             Accountability
             Interagency relations
             Congressional/executive relations
             Agency missions
             Health care programs
             Program management
             Information resources management
IDENTIFIER:  Medicare Program
             Medicaid Program
             Medicare Incentive Payment Program
             National Health Service Corps
             Head Start Program
             HHS Temporary Assistance for Needy Families Program
             HCFA Medicare Transaction System
             Medicare Choice Program
             GPRA
             Government Performance and Results Act
             
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Cover
================================================================ COVER


Before the Subcommittee on Labor, Health and Human Services,
Education and Related Agencies, Committee on Appropriations, House of
Representatives

For Release on Delivery
Expected at 2:00 p.m.
Thursday, February 26, 1998

DEPARTMENT OF HEALTH AND HUMAN
SERVICES - STRATEGIC PLANNING AND
ACCOUNTABILITY CHALLENGES

Statement of Richard L.  Hembra
Assistant Comptroller General
Health, Education, and Human Services Division

GAO/T-HEHS-98-96

GAO/HEHS-98-96t


(108357)


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

  CFO - Chief Financial Officers Act
  ACF - Administration for Children and Families
  BBA - Balanced Budget Act of 1997
  EDP - electronic data processing
  HHS - Department of Health and Human Services
  IG - Inspector General
  HCFA - Health Care Financing Administration
  MTS - Medicare Transaction System
  HMO - health maintenance organization
  HIPAA - Health Insurance Portability and Accountability Act of 1996
  OMB - Office of Management and Budget
  NIH - National Institutes of Health
  OCSE - Office of Child Support Enforcement
  PHS - Public Health Service
  SAMHSA - Substance Abuse and Mental Health Services Administration
  PPO - preferred provider organization
  PSO - provider sponsored organization
  TANF - Temporary Assistance for Needy Families

DEPARTMENT OF HEALTH AND HUMAN
SERVICES:  STRATEGIC PLANNING AND
ACCOUNTABILITY CHALLENGES
============================================================ Chapter 0

Mr.  Chairman and Members of the Subcommittee: 

I am pleased to be here today to discuss the challenges the
Department of Health and Human Services (HHS) faces in carrying out
its mission effectively and cost-efficiently and in improving its
accountability for the results of its efforts and its stewardship of
taxpayer dollars. 

One of the largest federal departments, HHS has diverse and complex
programs that warrant careful oversight.  In fiscal year 1997, HHS
had budget outlays of $339.5 billion and employed a workforce of over
57,000.  In addition, HHS is the federal government's largest
grant-making agency, providing approximately 60,000 grants a year. 
Its Medicare program is the nation's largest health insurer, handling
an estimated 900 million claims last year; Medicare alone spends far
more than most cabinet departments.  (See fig.  1.) Equally
important, 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. 

   Figure 1:  Fiscal Year 1997
   Outlays of the Four Largest
   Federal Agencies

   (See figure in printed
   edition.)

Note:  The Department of the Treasury's budget outlay was $379.3
billion.  However, $355.8 billion of that total was interest on the
public debt. 

I will begin my discussion today by focusing on HHS' progress in
strategic planning as envisioned by the Government Performance and
Results Act of 1993 (hereafter referred to as the Results Act).  The
Results Act presents HHS the opportunity to better manage the
Department at all levels, define the types of information it needs to
implement and assess its programs, and identify ways to progress
toward accomplishing its goals.  It also poses difficult challenges
to HHS, however, in meeting the requirements for preparing strategic
plans, designing performance measures, and assessing and reporting on
program accomplishments. 

In addition, I will highlight three underlying problems that we have
often reported as obstructing HHS' effective
functioning--coordinating and fixing accountability for its
approximately 300 diverse programs; ensuring that it has the
information systems it needs to manage and evaluate its programs and
track its progress in meeting performance goals; and protecting
programs vulnerable to fraud, waste, abuse, and mismanagement.  By
using the framework of the Results Act to address these underlying
problems, HHS will be much better able to carry out its vital
missions and assure the Congress and the American people that its
programs are achieving desired results. 

In summary, our work suggests that considering the breadth and
complexity of HHS' responsibilities, the size of its budget, and the
importance of its programs, it is essential that the Department
successfully and efficiently fulfill its mission.  We know that HHS
is committed to carrying out its programs effectively, but we and
others have often identified problems with HHS programs.  HHS
deserves credit for its progress in complying with the requirements
of the Results Act.  The next critical stage in improving HHS'
accountability for the public's investment in its programs will be to
move from its strategic planning efforts to efficiently accomplishing
its goals and objectives.  Successfully implementing HHS' plans will
require vigilance by the Department and its agencies as well as
continued congressional oversight. 


   RESULTS ACT AND RELATED
   LEGISLATION PROVIDE FRAMEWORK
   FOR IMPROVED PROGRAM
   PERFORMANCE, COST SAVINGS, AND
   ACCOUNTABILITY
---------------------------------------------------------- Chapter 0:1

Concerned that federal agencies have not always effectively managed
their activities to ensure accountability, the Congress created a
legislative framework to address long-standing governmentwide
management challenges.  The centerpiece of this framework is the
Results Act.  Other elements include the Chief Financial Officers
(CFO) Act, the Government Management Reform Act, the Federal
Financial Management Improvement Act, and the Clinger-Cohen Act.\1
These laws respond to the need for appropriate, reliable information
for executive branch and congressional decision-making. 


--------------------
\1 The 1990 CFO Act established a financial management leadership
structure and requirements for long-range planning, audited financial
statements, and strengthened accountability reporting.  The
Government Management Reform Act of 1994 requires each department and
major independent agency to submit to the Office of Management and
Budget (OMB) an audited agencywide financial statement beginning with
fiscal year 1996.  The Federal Financial Management Improvement Act
of 1996 is intended to improve federal accounting practices and
increase the government's ability to provide more reliable financial
information.  The Clinger-Cohen Act of 1996 elaborates on
requirements that promote the use of information technology to better
support agencies' missions and to improve program performance.  See
Managing for Results:  The Statutory Framework for Performance-Based
Management and Accountability (GAO/GGD/AIMD-98-52, Jan.  28, 1998). 


      RESULTS ACT INTENDED TO
      IMPROVE MANAGEMENT
      GOVERNMENTWIDE
-------------------------------------------------------- Chapter 0:1.1

The Results Act is aimed at improving program performance and
providing the Congress and the American people with the information
needed to assess whether government agencies are fulfilling their
missions.  It requires that agencies, in consultation with the
Congress and after soliciting the views of other stakeholders,
clearly define their missions and articulate comprehensive mission
statements that define their basic purposes.  It also requires that
agencies establish long-term strategic goals and link annual
performance goals to them.  Agencies must then measure their
performance according to the goals they have set and report publicly
on how well they are doing.  In addition to monitoring ongoing
performance, agencies are expected to evaluate their programs and to
use the evaluation results to improve programs. 

The Results Act requires virtually every executive agency to develop
a strategic plan covering a period of at least 5 years from the
fiscal year of its submission and to submit the plan to the Congress
and OMB.  OMB provided guidance on the preparation and submission of
strategic plans as a new part of its Circular No.  A-11--the basic
instructions for preparing the president's budget--to underscore the
link between the Results Act and the budget process.  The strategic
plans are to include six elements:  (1) a mission statement, (2)
long-term goals and objectives, (3) approaches or strategies to
achieve the goals and objectives, (4) a discussion of the
relationship between long-term goals and annual performance goals,
(5) key external factors beyond the agency's control that affect
goals and objectives, and (6) evaluations used to establish goals and
objectives and a schedule for future evaluations. 

HHS, as required by the Results Act, submitted its first strategic
plan to OMB and the Congress on September 30, 1997.  In addition, the
act requires agencies to submit annual performance plans tied to
their budget requests to reinforce the connection between the
long-term strategic goals outlined in the strategic plans and the
daily activities of program managers and staff.  HHS submitted its
first annual performance plan, for fiscal year 1999, in early
February.  In response to a request from the Speaker, Majority
Leader, and several committee chairmen of the House of
Representatives, we are evaluating that plan.  In addition, at the
request of the Chairman of the Appropriations Committee and others in
the House and Senate leadership, we developed a guide to help
decisionmakers both elicit the information that the Congress needs
from agencies' annual performance plans and assess the quality of
those plans.\2


--------------------
\2 See Agencies' Annual Performance Plans Under the Results Act:  An
Assessment Guide to Facilitate Congressional Decisionmaking
(GAO/GGD/AIMD-10.1.18, version 1, Feb.  1998). 


      HHS CAN USE RESULTS ACT TO
      CLARIFY AND MEET ITS GOALS
      AND OBJECTIVES
-------------------------------------------------------- Chapter 0:1.2

The Results Act offers HHS a valuable and useful management
framework, shifting attention to data and performance measures that
will allow the Department and the Congress to judge whether programs
are accomplishing their purposes.  Although meeting the act's
requirements will challenge HHS, employing the discipline of the
planning process could improve the Department's performance and
accountability--vital goals when resources are limited and public
demands are high. 

The benefit of emphasizing program results instead of inputs and
outputs is illustrated by our evaluations of several programs related
to one of HHS' six strategic goals--improving access to health
services and ensuring the integrity of the nation's health
entitlement and safety net programs.  In the past several years, we
have issued several reports examining federal efforts to improve
access to primary health care.  The federal government spends
billions of dollars each year on health financing and service
delivery programs that, in whole or part, are aimed at achieving this
objective.  We found that although federal programs have provided
resources to improve access to primary health care, the programs have
not been held accountable for showing that access has indeed
improved.  Following are some examples: 

  -- Medicare and Medicaid payment methods for rural health
     clinics--whose original purpose was to subsidize health care in
     remote rural areas lacking physicians--now cost more than $295
     million a year to primarily subsidize care in cities and towns
     that already have substantial health care resources.\3 Our
     review of a sample of clinics showed that the availability of
     care did not change appreciably for at least 90 percent of
     Medicare and Medicaid beneficiaries using the clinics.  Staff we
     interviewed at most clinics said they did not use the subsidies
     to expand access to underserved portions of the population or
     need the subsidies to remain financially viable.\4

  -- The Medicare Incentive Payment program, created out of concern
     that physicians would not treat Medicare patients because of low
     Medicare reimbursement rates, pays all physicians in designated
     shortage areas a 10-percent bonus on Medicare billings. 
     Physicians receive bonus payments now totaling over $100 million
     each year, even in shortage areas where Medicare patients are
     not underserved or where low Medicare reimbursement rates are
     not the cause of underservice.\5

  -- Federal and state programs placing providers in underserved
     areas have oversupplied some communities and states with
     providers while other areas have received no providers.  For the
     National Health Service Corps program alone, at least 22 percent
     of shortage areas receiving National Health Service Corps
     providers in 1993 received providers exceeding the number needed
     to remove federal designation as a shortage area,\6 while 785
     shortage areas requesting providers received no providers at
     all.  Of these latter areas, 143 had requested a National Health
     Service Corps provider for 3 years or more but received none.\7

  -- Although almost $2 billion has been spent in the last decade on
     health professional education and training programs, HHS has not
     gathered the information necessary to evaluate these programs'
     effect on changes in the national supply, distribution, or
     minority representation of health professionals or their impact
     on access to care.  Evaluations often did not address these
     issues, and those that did address them had difficulty
     establishing a cause-and-effect relationship between federal
     program funding and any changes that occurred.\8

The Results Act provides an opportunity for HHS to make sure its
programs to improve access to health care are on track and to
identify how each program's efforts will contribute to overall access
goals.  Establishing the following performance goals and measures,
for example, could significantly improve accountability in HHS'
primary health care access programs: 

  -- HHS now tracks the number of rural health clinics established
     and the number of physicians receiving health shortage area
     bonus payments and dollars spent.  To measure access outcomes,
     HHS would need to assess whether these programs have improved
     access to care for Medicare and Medicaid populations or other
     underserved populations. 

  -- The success of the National Health Service Corps and health
     center programs has been based on the number of providers placed
     or the number of people they served.  To measure access
     outcomes, HHS would need to gather the information necessary for
     reporting the number of people receiving care from National
     Health Service Corps providers or from the health centers who
     were otherwise unable to gain access to the local community's
     primary care services. 

The $4.4 billion Head Start program provides another example of how
the Results Act's requirement that agencies substantiate program
results can help HHS improve accountability.  Although an extensive
body of research exists on Head Start, only a small part of this
addresses the program's impact.  This body of research does not
provide an adequate basis for drawing conclusions about the impact of
the national program in any area in which Head Start provides
services, including children's social and cognitive readiness for
school.\9 Head Start has recently developed performance measures to
assess program results and outcomes. 


--------------------
\3 This is the estimated additional cost to the Medicare and Medicaid
programs due to higher payment rates to rural health clinics. 

\4 We reviewed the health care resources of a sample of communities
where 144 rural health clinics were certified in four states: 
Alabama, Kansas, New Hampshire, and Washington.  We analyzed past
access to care for Medicare and Medicaid beneficiaries using 119 of
these clinics and subsequently interviewed staff at 76 of the
clinics.  See Rural Health Clinics:  Rising Program Expenditures Not
Focused on Improving Care in Isolated Areas (GAO/HEHS-97-24, Nov. 
22, 1996) and related testimony (GAO/T-HEHS-97-65, Feb.  13, 1997). 

\5 See Health Care Shortage Areas:  Designations Not a Useful Tool
for Directing Resources to the Underserved (GAO/HEHS-95-200, Sept. 
8, 1995). 

\6 In creating the federal health professional shortage area
designation system, federal intervention was considered justified
only if the number of health care providers was significantly less
than adequate, indicating that the needs of these areas were not
being met through free-market mechanisms or reimbursement programs. 

\7 See National Health Service Corps:  Opportunities to Stretch
Scarce Dollars and Improve Provider Placement (GAO/HEHS-96-28, Nov. 
24, 1995). 

\8 See Health Professions Education:  Role of Title VII/VIII Programs
in Improving Access to Care Is Unclear (GAO/HEHS-94-164, July 8,
1994) and Health Professions Education:  Clarifying the Role of Title
VII and VIII Programs Could Improve Accountability (GAO/HEHS-97-117,
Apr.  25, 1997). 

\9 See Head Start:  Research Provides Little Information on Impact of
Current Program (GAO/HEHS-97-59, Apr.  15, 1997). 


      HHS' STRATEGIC PLAN CONTAINS
      KEY ELEMENTS BUT CAN BE
      FURTHER IMPROVED
-------------------------------------------------------- Chapter 0:1.3

HHS met its first major milestone of the Results Act in September
when it submitted its first 5-year strategic plan to the Congress. 
The plan represents a serious initial effort toward integrating
program goals and activities at a departmental planning level,
meeting the requirements of the Results Act, and providing the
Congress with a useful document to inform its oversight and
appropriation responsibilities.  The plan includes all six critical
elements required by the Results Act, including a mission statement
that successfully captures the broad array of the Department's
activities, six overarching Department-wide goals, and objectives for
accomplishing these six goals.  The objectives focus largely on
outcomes, such as reducing the use of illicit drugs, and they are
defined in measurable terms, such as increasing the percentage of the
nation's children and adults who have health insurance coverage.  The
plan also identifies key measures of progress for each strategic
objective.  For example, one measure for determining reduced tobacco
use is the rate of tobacco use by young people. 

The plan describes HHS' activities to coordinate efforts both
internally among its operating divisions and externally with other
departments and agencies that have related missions.  HHS' plan also
recognizes three types of challenges that could significantly affect
the Department's ability to achieve its strategic goals:  external
factors, such as the poverty rate among children; management issues,
such as resource constraints; and data problems, such as the limits
of current data administration systems. 

In our review of HHS' strategic plan for the Congress, we discussed
several opportunities for improving the plan.\10 HHS officials agreed
that the plan can be further improved, noting that strategic planning
is a continuous process.  They observed that ongoing assessments and
updates will be needed to strengthen the plan and ensure that it
continues to provide relevant direction for HHS' program activities. 

HHS' greatest opportunities for improving its strategic plan, in our
view, involve discussion of the Department's strategies for
accomplishing its objectives.  First, the plan does not clearly link
its strategies to the attendant measures of success, making it
difficult to determine the strategies' contribution to the desired
outcomes.  For example, to increase the economic independence of
families on welfare, the plan specifies three strategies:  providing
technical assistance, promoting employment, and improving access to
child care.  The plan's four measures of success for economic
independence, however, all relate to providing employment, with no
apparent relationship to the strategies for providing child care or
technical assistance. 

Another area of the plan in which linkage between strategies and
measures of success can be improved involves HHS' sixth strategic
goal--strengthening the nation's health sciences research enterprise
and enhancing its productivity.  Achieving this goal is a major
function of the National Institutes of Health (NIH), which accounts
for over a third of HHS' discretionary funds.  The strategic plan's
proposed measures of success for achieving this goal--for example,
changes in the treatments for disease and disability--are too broad
for effectively evaluating the impact of NIH's program activities. 
Assessing research outcomes is especially difficult due to a
combination of factors--the unpredictable nature of research, the
time lag between program inputs and results, and the problem in
determining a causal link between specific research projects and
results.  Despite these difficulties, NIH must be held accountable
for demonstrating that it is achieving intended results with its
annual expenditures, $11.2 billion in fiscal year 1997. 

A second concern is that HHS' strategic plan does not discuss the
effectiveness of the outlined strategies.  The plan mentions neither
existing evaluations to indicate current knowledge of these
strategies' effectiveness nor plans for future evaluations to
determine their effectiveness.  For example, some of the strategies
are based on a common HHS approach to support state-administered
programs:  technical assistance, training, and identifying and
disseminating best practices.  Yet, we have found in our work on
these programs, such as child protective services and child support
enforcement, that such strategies have presented problems.  In some
cases, HHS' technical assistance was inadequate, the regional offices
had only a limited capacity to provide assistance and training, and
HHS' dissemination of research and best practices was lacking.  In
addition to drawing on past evaluations, HHS' plans should identify
future evaluations to determine the effectiveness of its strategies. 
Such evaluations are essential for determining whether taxpayer
dollars are invested wisely. 

Third, the plan does not discuss the resources required to implement
the strategies.  For example, strategies to enhance the fiscal
integrity of the Health Care Financing Administration (HCFA) programs
include consolidating Medicare payment systems to improve HHS'
ability to identify aberrant billing and improve payment accuracy. 
The plan does not mention, however, the resources necessary to
implement such a strategy. 

Fourth, although the plan identifies key external factors that could
impede HHS' achieving its strategic goals and objectives, there is
little discussion of how the Department intends to address these
factors.  For example, a key external factor to achieving several HHS
objectives is the state of the economy.  However, the plan does not
indicate how its strategies would adjust to changes in the economy
that could, for example, increase the number of Medicaid-eligible
children. 

In addition, although the plan reflects a recognition of management
and information challenges to achieving HHS' goals, it provides
little discussion of potential solutions.  For example, the plan
acknowledges HHS' reliance on state, local, and tribal governments;
contractors; and private entities as program and information partners
and mentions the need to coordinate with them but does not specify
how it would do so.  Similarly, while HHS' plan recognizes the
importance of improving its financial management information, it does
not specify the corrective actions and timetables needed to obtain an
unqualified or clean opinion on its financial statements.  Finally,
although the plan identified several information technology
initiatives that may help HHS achieve some program objectives, the
plan does not discuss how HHS intends to identify and coordinate
information technology investments to support overall Department-wide
goals and missions. 


--------------------
\10 See Managing for Results:  Agencies' Annual Performance Plans Can
Help Address Strategic Planning Challenges (GAO/GGD-98-44, Jan.  30,
1998). 


   SCOPE OF HHS' RESPONSIBILITIES
   MAKES COORDINATION AND
   ACCOUNTABILITY DIFFICULT
---------------------------------------------------------- Chapter 0:2

The sheer size and scope of HHS' mission and the resulting
organizational complexity make it especially challenging for the
Department to manage and coordinate its programs to give the public
the best possible results and to preclude agencies' duplicating or
undermining each other's efforts.  HHS comprises 11 operating
agencies, each of which manages a number of programs, whose many
parts also must be administered.  (See fig.  2.) For example, NIH is
only one of the agencies within the Public Health Service (PHS), yet
NIH includes 17 separate health institutes, the National Library of
Medicine, and the National Center for Human Genome Research.  HCFA
administers the Medicare and Medicaid programs, as well as several
quality of care programs such as those authorized by the Clinical
Laboratory Improvement Amendments of 1988.  The Administration for
Children and Families (ACF) is responsible for about 60 programs,
including the new federal-state welfare program; child support
enforcement; and Head Start, which alone serves about 800,000
children.  This array of interrelated activities and responsibilities
makes it especially important for HHS managers to work together to
address the Department's overarching program goals. 

   Figure 2:  HHS' Major Operating
   Divisions

   (See figure in printed
   edition.)


      BETTER INTERNAL AND EXTERNAL
      COORDINATION COULD IMPROVE
      PROGRAM RESULTS AND MORE
      EFFICIENTLY USE FEDERAL
      FUNDS
-------------------------------------------------------- Chapter 0:2.1

Coordination among HHS programs with related responsibilities is
essential to efficiently and effectively meeting program goals. 
Moreover, many HHS programs share goals with or relate closely to
programs administered by other federal agencies.  In addition to
coordinating the activities of its own agencies, HHS must also
coordinate its efforts with these other agencies.  Furthermore, a
number of HHS programs, including Medicaid and Temporary Assistance
for Needy Families (TANF) block grants, require both federal and
state involvement.  Therefore, HHS must work with all the state
governments--and at times local jurisdictions--to coordinate
implementation of these programs. 

Implementing the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 and subsequent legislation, for example,
requires HHS to focus on both internal and external coordination. 
Employment, training, and education programs administered by the
Departments of Labor and Education will probably be essential to HHS'
goal of promoting self-sufficiency and parental responsibility for
poor families receiving assistance through TANF block grants. 
Coordinating Head Start and other HHS child care programs may help
low-income families gain access to the child care they need to find
or maintain employment.  In addition, HHS substance abuse and mental
health programs may play an important role in helping welfare
families with multiple barriers to employment move toward
self-sufficiency. 

Other examples of program areas requiring both internal and external
coordination include alcohol and other drug abuse treatment and
prevention, child abuse and neglect, and child support enforcement. 
For example, programs addressing alcohol and other drug abuse issues
reside not only in several HHS agencies--including the Substance
Abuse and Mental Health Services Administration, NIH, ACF, and the
Centers for Disease Control and Prevention--but also in 15 other
federal agencies.  These include the Departments of Education,
Housing and Urban Development, Justice, and Veterans Affairs.\11 HHS
also administers 58 programs that address the problems of at-risk and
delinquent youth.  An additional 73 programs focused on this
population reside in 15 other federal departments and agencies,
including the Departments of Agriculture, Education, Housing and
Urban Development, Justice, and Labor.\12 In addition to coordinating
within the government, HHS must also coordinate its activities with
many private organizations.  For example, HCFA must coordinate with
about 70 Medicare claims contractors, more than 400 managed care
plans, insurance companies providing supplemental coverage to
Medicare beneficiaries, and beneficiary and provider associations. 


--------------------
\11 See Drug and Alcohol Abuse:  Billions Spent Annually for
Treatment and Prevention Activities (GAO/HEHS-97-12, Oct.  8, 1996). 

\12 See At-Risk and Delinquent Youth:  Multiple Federal Programs
Raise Efficiency Questions (GAO/HEHS-96-34, Mar.  6, 1996). 


      PARTNERSHIP WITH STATE AND
      LOCAL AGENCIES MAKES
      ACCOUNTABILITY FOR RESULTS
      DIFFICULT
-------------------------------------------------------- Chapter 0:2.2

Many HHS programs are operated by states, localities, or
nongovernmental organizations, which requires HHS agencies to develop
ways to make their many partners accountable for program results. 
The Department has observed in its fiscal year 1999 performance plan
that virtually all of the approximately $400 billion that will be
expended for HHS programs in that year will be spent not by HHS
employees--but by program partners.  In administering programs that
are the joint responsibility of state governments or that involve
many local grantees, HHS must continually balance program flexibility
with oversight and maintaining program controls.  To further
complicate HHS' task, state data necessary for meaningful performance
measurement may not be available or may not be comparable from state
to state. 

Managing the TANF block grant exemplifies many of these difficulties. 
Under TANF, states have flexibility in designing and implementing
their own assistance programs within federal guidelines.  Meanwhile,
HHS has a broad range of responsibilities for ensuring accountability
from the states.  The law also gives HHS authority to assess
penalties if states fail to comply with certain requirements and
provides for states to receive bonuses if they meet certain
performance standards.  HHS must work closely with the states to
develop effective performance measures that promote the goals of the
1996 welfare law.  The experience of the Office of Child Support
Enforcement (OCSE) in working with states to develop national goals
and objectives for the child support enforcement program demonstrated
that although developing performance measures for federal-state
programs is a challenge, HHS and its state partners can, with time
and effort, make progress toward producing results-oriented program
management.\13

Administering the Medicaid program presents the same difficulty in
balancing flexibility and accountability.  Federal statutes and
regulations allow states substantial flexibility in designing and
administering their Medicaid programs.  Flexibility can be positive
for beneficiaries as well as the states; however, HCFA's ongoing
monitoring and oversight are essential to ensure the appropriate use
of federal funds. 

Another example is Head Start, which was designed to ensure maximum
local autonomy.  The accountability structure established to oversee
the program is based on largely self-enforcing performance standards. 
Head Start performs on-site monitoring reviews every 3 years to
ensure that its more than 1,400 grantees are in compliance with the
standards.  Head Start supplements information from these reviews
with data grantees provide annually about their program activities. 
These annual data are self- reported and unvalidated.  Several HHS
Office of the Inspector General (IG) reports have raised questions
about accountability in Head Start.  For example, a May 1993 report
found significant differences between the number of services grantees
reported they had provided and the number they had actually
documented in their files.  The IG also found that grantee files and
records were often incomplete, inconsistent, and hard to review.\14


--------------------
\13 See Child Support Enforcement:  Reorienting Management Toward
Achieving Better Program Results (GAO/HEHS/GGD-97-14, Oct.  25,
1996). 

\14 Evaluating Head Start Expansion Through Performance Indicators,
HHS Office of Inspector General, OEI-09-91-00762 (May 1993) and
Summarization of Concerns With the Financial Management Systems and
Control Structures Found at Head Start Grantees, HHS Office of the
Inspector General, A-17-93-00001 (Sept.  1993). 


   RELIABLE AND COMPREHENSIVE
   MANAGEMENT INFORMATION SYSTEMS
   CRUCIAL TO HHS SUCCESS
---------------------------------------------------------- Chapter 0:3

To effectively manage its large health insurance programs, extensive
grant-making activities, and vital regulatory responsibilities, HHS
must have access to data about its programs and their effects that
are both reliable and appropriate to the task.  Without these data,
HHS will not know whether it is accomplishing its goals or its
programs' effect on the American people.  Nor will HHS be able to
give the Congress the information it needs to evaluate the
Department's success.  Creating and implementing the sophisticated
systems to give HHS managers the data they need presents a major
challenge.  Because several important HHS programs, including
Medicaid and TANF, are joint federal-state endeavors, the current
lack of comparable state data increases the difficulty of obtaining
timely and reliable data.  Another critical task related to
information management is HHS' timely resolution of the "year 2000"
problem. 


      WELFARE REFORM PRESENTS HHS
      WITH MANY INFORMATION
      CHALLENGES
-------------------------------------------------------- Chapter 0:3.1

The new welfare reform law gives HHS new administrative and oversight
responsibilities, the performance of which will rely on
state-provided data.  HHS needs to ensure that it receives comparable
and reliable data from the states to help it fulfill its oversight
responsibilities under the new legislation, namely, ensuring that
states enforce the federal 5-year time limit on receiving welfare
benefits, meet minimum work participation rates, and maintain a
certain level of welfare spending.  Enforcing the time limit, for
example, will be difficult because information on the total amount of
time someone has received welfare is often unavailable in a state,
let alone across states.  In addition, HHS will need to collect state
data to determine performance penalties and bonuses.  With the
increased flexibility of states in designing their programs,
obtaining comparable and reliable data to assess the effect of
welfare reform on children and families could be difficult for HHS. 

Similarly, to strengthen child support enforcement, HHS is required
to use state-provided data to establish a national directory of newly
hired employees and registry of child support orders so these data
can be cross matched.  In addition, the law requires HHS to
implement, by fiscal year 2000, a new child support enforcement
incentive structure that will be based on performance data generated
by statewide information systems that are not yet fully implemented
or certified.  We reported in 1997 that OCSE's mandatory oversight of
state systems has been narrowly focused and, as a result, neither
effective nor timely in assessing state systems' approaches and
progress.\15


--------------------
\15 See Child Support Enforcement:  Leadership Essential to
Implementing Effective Automated Systems (GAO/T-AIMD-97-162, Sept. 
10, 1997) and Child Support Enforcement:  Strong Leadership Required
to Maximize Benefits of Automated Systems (GAO/AIMD-97-72, June 30,
1997). 


      HCFA NEEDS BETTER
      INFORMATION ABOUT ENROLLEES
      AND SERVICES TO MANAGE
      MEDICAID PROGRAM
-------------------------------------------------------- Chapter 0:3.2

HHS also faces information challenges in managing the $168 billion
Medicaid program.  Medicaid, a joint federal-state program
administered by HCFA, provides health coverage for 36 million
low-income people, including 17.6 million children.  Medicaid also
pays for nursing home coverage for low-income elderly and other
vulnerable members of society, accounting for almost half of total
national spending for nursing home care.  The Medicaid program's
federal fiscal year 1997 expenditures totaled about $96 billion, with
state expenditures totaling about $72 billion. 

Despite the size of the Medicaid program, the federal government has
only limited data on its results and the accuracy of these data is
questionable.  Using state-supplied information, HCFA creates a
statistical report that has data about beneficiaries served, their
eligibility categories, types of services they received, and vendor
payments.  It also generates a regular financial report.  Problems
with the accuracy and consistency of the state data, however,
compromise the usefulness of these reports.  Some of these problems
stem from collecting data from 50 states and the District of
Columbia, which do not all identically define data categories.  An
additional limitation is the difficulty of crosswalking some types of
information between these two reports.  Problems in the quality of
the data and in the ability to link data across data sources make it
difficult for HCFA and others to analyze and evaluate Medicaid's
results. 

For example, HCFA has had a problem with duplicate reporting on the
number of people enrolled in Medicaid managed care programs. 
Furthermore, Medicaid's data problems could worsen because of the
program's growing reliance on managed care to provide health services
to beneficiaries.  The proportion of Medicaid beneficiaries enrolled
in managed care, as reported by HCFA, quadrupled from about 10
percent in 1991 to about 40 percent in 1996.  Because Medicaid pays
many managed care organizations a defined fee for providing a range
of services, HCFA usually lacks the detailed utilization data that
are available under the fee-for-service billing system.  These data
problems make it difficult to assess the effect of managed care on
Medicaid services and costs. 

An additional challenge will arise as HCFA and the states begin to
implement the new $20.3 billion Children's Health Insurance Program. 
HCFA needs to provide timely guidance to the states on data reporting
to allow them to collect uniform information on beneficiaries, costs,
and services.  This would then supply HCFA with the uniform
aggregated data it will need to assess the program's effects. 


      INFORMATION MANAGEMENT
      CRITICAL TO PREVENT FRAUD
      AND ABUSE IN THE MEDICARE
      PROGRAM
-------------------------------------------------------- Chapter 0:3.3

HHS faces vast information management challenges regarding the
Medicare program, which accounts for over half of HHS' annual budget. 
The Medicare Transaction System (MTS) was intended to create a single
integrated database of information on all beneficiaries, providers,
and plans as well as to perform functions such as claims processing
and managed care enrollment.  If properly planned and designed, MTS
could have played an important role in reducing Medicare fraud and
abuse.  Such a single integrated database would, for example, have
helped prevent unscrupulous providers from billing multiple
contractors for the same service or piece of medical equipment. 
Throughout its development, the MTS project was fraught with design
and management problems that increased its cost and risk.  In August
1997, HCFA determined that the contractor could not deliver the
system on schedule and within budget and terminated the contract as
of January 1, 1998.  While exploring other strategies to improve its
systems for Medicare, HCFA is working to improve the efficiency of
its claims process by reducing the number of claims processing
systems from eight to three, one of which will process only durable
medical equipment claims. 


      HHS MUST ACT QUICKLY TO
      REDUCE YEAR 2000 RISK
-------------------------------------------------------- Chapter 0:3.4

As we approach the year 2000, information systems worldwide could
malfunction or produce incorrect information simply because they have
not been designed to handle dates beyond 1999.  Unless this problem
is resolved ahead of time, every federal agency--including HHS--faces
risk of massive system failures.  The impact of these failures could
be widespread and costly.  For example, HCFA expects to process over
1 billion Medicare claims and pay $288 billion in benefits a year by
2000. 

HHS' progress in preparing for the year 2000 has been too slow:  less
than 25 percent of its mission-critical systems have been converted
and tested.  As a result, in its November 15, 1997, report on the
progress on year 2000 conversion, OMB placed HHS on its list of
agencies that had not made sufficient progress to date, which could
result in restrictions on HHS' funding for information technology
investments unless they are directly related to correcting the year
2000 problem.  These restrictions would remain in place until HHS
demonstrates that it is adequately addressing this problem. 

We reported in May 1997 that HCFA was relying on its Medicare systems
contractors to assess, plan, and implement essential changes for the
year 2000 issue but was not closely monitoring these activities or
receiving certifications or assurances from contractors that they
will address the problems.\16 HCFA has since hired a chief
information officer to address these and other technology issues. 
The scope of contractors' needed work is much broader than past
systems changes contractors have had to make.  It requires reviewing
all software programs and systems interfaces and components that can
be affected by the year 2000 problem; this includes hardware,
operating systems, communications applications, and databases. 
Unless timely, effective systems changes are implemented as the year
2000 approaches, HCFA may be unable to process claims accurately and
within required time frames. 


--------------------
\16 See Medicare Transaction System:  Success Depends Upon Correcting
Critical Managerial and Technical Weaknesses (GAO/AIMD-97-78, May 16,
1997). 


   SAFEGUARDING VULNERABLE
   PROGRAMS REQUIRES CONSTANT
   VIGILANCE AND INNOVATION
---------------------------------------------------------- Chapter 0:4

With HHS' broad range of programs, large number of grantees and
contractors, huge volume of vendor payments, and millions of
beneficiaries, the Department must always be vigilant in protecting
its programs from fraud, waste, abuse, and mismanagement.  The sheer
dollar size of HHS' programs makes them attractive targets, and the
consequences can be severe.  HHS needs to improve its processes for
identifying and preventing fraud, waste, abuse, and mismanagement and
maintain constant vigilance in the future.  The $200 billion Medicare
program exemplifies the importance of such efforts. 


      INHERENT VULNERABILITIES
      RESIDE IN PROGRAM OF
      MEDICARE'S SIZE AND SCOPE
-------------------------------------------------------- Chapter 0:4.1

Most Medicare services are provided through the fee-for-service
sector, where any qualified provider can bill the program for
services rendered.  In fiscal year 1997, Medicare processed an
estimated 900 million claims.  Through its claims processing
contractors, Medicare pays hundreds of thousands of providers, such
as physicians, hospitals, skilled nursing facilities, home health
agencies, and medical equipment suppliers.  In addition, HCFA pays
and monitors more than 400 managed care health plans that serve more
than 5 million beneficiaries.  The managed care program consists
mostly of risk contract health maintenance organizations (HMO). 
Medicare pays these HMOs a monthly amount, fixed in advance, for all
the services provided to each beneficiary enrolled.  Both the
fee-for- service and managed care delivery systems have
vulnerabilities. 

Inherent in Medicare's fee-for-service program--used by about 87
percent of the program's beneficiaries--is an incentive for providers
to deliver more services than necessary, driving up program costs. 
Spending growth for services until now not subject to cost
containment reforms--such as home health care and skilled nursing
facility care--has skyrocketed, growing much faster than spending for
inpatient and physician services.  Policymakers have therefore looked
to the managed care experience of private-sector payers for
solutions.  Prepaid plans have appeal for Medicare because, in
principle, they are designed to contain health care costs and limit
the excess utilization encouraged by fee-for-service reimbursement. 
No payment method is perfect, however:  the method of paying
providers a fixed amount in advance creates an incentive for
providers to skimp on services to increase profits at the expense of
quality care. 


      LEGISLATIVE REFORMS
      SUBSTANTIALLY INCREASE
      HCFA'S AUTHORITY TO MANAGE
      THE MEDICARE PROGRAM
-------------------------------------------------------- Chapter 0:4.2

Two recent acts grant HCFA substantial authority and responsibility
to reform Medicare.  The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) provides the opportunity to
enhance Medicare's antifraud and abuse activities.  The Balanced
Budget Act of 1997 (BBA) introduces new health plan options and major
payment reforms.  These two acts address in large measure our
concerns and those of the HHS IG regarding the tools needed to combat
fraud and abuse.\17 They also address many of the weaknesses
discussed in our High-Risk Series report on Medicare.\18 The
effectiveness of these new antifraud and abuse tools provided by
HIPAA and BBA, however, will depend on their being well designed and
promptly implemented. 

HIPAA created for the first time a stable source of funding for
Medicare fraud control.  For fiscal year 1997, the act provides for
up to $440 million for program safeguard activities; funding will
rise incrementally each year, reaching $720 million in fiscal year
2003, after which it will remain constant.  This was a significant
step in reversing the trend of declining program safeguard funds
relative to program growth in the 8 years before fiscal year 1997,
when HIPAA funding provisions became effective.  This funding comes
from a HIPAA-established fraud-and-abuse control account that also
funds other activities involving other HHS agencies and the
Department of Justice.  HIPAA also provides HCFA with explicit
authority to contract with firms outside its existing claims
processing contractor network to perform payment safeguard functions,
while avoiding conflicts of interest.  In addition, HIPAA adds new
civil and criminal penalties to previously little-used enforcement
powers. 

BBA dramatically expanded health plan choices for Medicare
beneficiaries and reformed payment methods in traditional
fee-for-service Medicare and managed care plans.  Under the act's new
Medicare+Choice program, beneficiaries will have new health plan
options, including preferred provider organizations (PPO), provider
sponsored organizations (PSO), and private fee-for-service plans. 
Medicare+Choice introduces new consumer information and protection
provisions, including a requirement to distribute comparative
information on Medicare+Choice plans in beneficiaries' communities
and a requirement that all Medicare+Choice plans obtain external
review from an independent quality assurance organization.\19 These
provisions address problems we have worked with the Congress to
correct and give HCFA newly mandated consumer protection and
oversight responsibilities for a potentially larger number of
plans.\20

BBA also provided for revamping many of Medicare's decades-old
payment systems to contain the unbridled growth in certain program
components.  Specifically, the act mandated prospective payment
systems for services provided by about 1,100 inpatient rehabilitation
facilities, 14,000 skilled nursing facilities, 5,000 hospital
outpatient departments, and 8,900 home health agencies.  In addition,
it changed the payment methods for hospitals, including payments for
direct and indirect medical education costs.  It also adjusted
fee-schedule payments for physicians and durable medical equipment
and authorized converting the remaining reasonable charge payment
systems to fee schedules.  Finally, the act granted the authority to
conduct demonstrations on the cost-effectiveness of purchasing items
and services through competitive bids from suppliers and providers. 


--------------------
\17 See Medicare Fraud and Abuse:  Summary and Analysis of Reforms in
the Health Insurance Portability and Accountability Act of 1996 and
the Balanced Budget Act of 1997 (GAO/HEHS-98-18R, Oct.  9, 1997). 

\18 See High-Risk Series:  Medicare (GAO/HR-97-10, Feb.  1997). 

\19 BBA authorized the Secretary of HHS, subject to appropriations,
to collect $200 million in user fees to conduct information
activities associated with Medicare+Choice.  Subsequently, in the HHS
appropriation, the Secretary was given authority to collect $95
million of the originally authorized amount for this purpose.  HCFA
was also appropriated between $20 million and $30 million for the
administration of BBA-related activities. 

\20 See Medicare:  HCFA Should Release Data to Aid Consumers, Prompt
Better HMO Performance (GAO/HEHS-97-23, Oct.  22, 1996) and Medicare: 
Opportunities Are Available to Apply Managed Care Strategies
(GAO/T-HEHS-95-81, Feb.  10, 1995). 


      EFFECTIVE MANAGEMENT OF
      RESOURCES AND HCFA
      LEADERSHIP NEEDED TO PROTECT
      INTEGRITY OF MEDICARE
      PROGRAM
-------------------------------------------------------- Chapter 0:4.3

While legislative reforms are dramatically reshaping Medicare, other
changes are occurring, increasing difficult management challenges.\21
For example, HCFA is rethinking its strategy to develop, modernize,
or otherwise improve the agency's multiple automated claims
processing and other information systems.  HCFA is also confronting
transition problems resulting from the recent loss of large-volume
claims processing contractors and the need for remaining contractors
to absorb the workload.  Finally, HCFA recently restructured its
organizational units to better focus on its mission and is
experiencing the kind of disruptions common to organizational
transitions. 

Our recent work at HCFA interviewing senior and mid-level managers
indicates that distribution of agency resources, need for specialized
expertise, loss of institutional experience, and reorganization are
serious management problems that could increase program
vulnerability.  In the case of agency resources, managers were
concerned that the concentrated efforts to implement BBA and solve
computer problems that could arise in the year 2000 could compromise
the quality of other work or that tasks might be neglected
altogether.  For example, regional and headquarters officials who
oversee claims processing contractors told us that their capacity to
monitor contractors had severely diminished.  One region that
formerly had six staff members dedicated to contractor oversight now
has two; the other staff, they said, had been reassigned to work on
managed care issues.  This concerns us because, in the past several
years, we have reported that HCFA has not adequately ensured that
contractors are paying only medically necessary claims. 

Managers also expressed a common concern about the staff's mix and
level of skills.  As an illustration, the Medicare+Choice program
introduces new health plan types and requires distributing
information on the plans to beneficiaries in 1998.  Called the
Medicare+Choice Information Fair, this nationwide educational and
publicity campaign will be HCFA's first effort of this kind. 
Managers were concerned that inexperienced staff will need to gather
information that describes and evaluates the merits of various plans. 

Managers also cited the loss of experienced staff as a problem for
developing and implementing the various prospective payment systems
mandated by BBA.  They noted that developing one new payment system
would have been manageable, but losses of expert staff make it
difficult to implement multiple new payment systems concurrently.\22

In addition, managers noted the difficulties of simultaneously
implementing recent legislative reforms, responding to critical
information system problems, and carrying out a major agency
reorganization.  In July 1997, HCFA restructured its entire
organization to, among other things, redirect additional resources to
the growing managed care side of the program; acknowledge a shift
from HCFA's traditional role as claims payer to its role as purchaser
of health care services; and sharpen the focus on beneficiaries,
health plans and providers, and state-level activities.  Although
generally favoring the reorganization in concept, managers described
their difficulties in establishing new communication and coordination
links within units and agencywide.  They noted that the situation was
particularly acute because people have not yet moved to their new
units' actual locations. 

HCFA managers appeared to be clear about top management's
expectations for completing BBA-related activities and for making
sure that contractors' claims processing systems would comply with
the millennium changes.  They were less certain, however, about the
agency's strategy for meeting other mission-related work.  One
example of this uncertainty concerns the legislative mandates for
reporting to the Congress on specific topics such as Medicare's
reimbursement of telemedicine services.  Currently, the agency's top
managers do not compile a list of reports due and their deadlines. 
Unit managers are concerned because, although they know that certain
reports they must produce will be late, they have no systematic way
to keep top management informed.  Top management, in turn, cannot
decide whether to raise the priority for a particular report or
develop a strategy to mitigate the consequences of others being late. 

The illustration above and our discussions with agency officials
suggest that although HCFA may be ready to assert its BBA-related
resource needs, it is not likely to be able to adequately justify the
resources it seeks to implement its other Medicare program
objectives.  In short, because senior managers do not appear to be
adequately informed about the status of the range of Medicare
activities or associated resource needs, HCFA's senior decisionmakers
cannot determine whether resources are adequate or properly
distributed and which activities could be at risk of neglect. 


--------------------
\21 See Medicare:  HCFA Faces Multiple Challenges to Prepare for the
21st Century (GAO/T-HEHS-98-85, Jan.  29, 1998). 

\22 See Medicare:  Recent Legislation to Minimize Fraud and Abuse
Requires Effective Implementation (GAO/T-HEHS-98-9, Oct.  9, 1997). 


      HCFA'S FINANCIAL STATEMENT
      AUDITS CONTINUE TO HAVE
      PROBLEMS
-------------------------------------------------------- Chapter 0:4.4

An additional area of Medicare vulnerability on which we have
previously reported is HHS' difficulty in complying with the
requirements of the Government Management Reform Act of 1994.  The
HHS IG could not express an opinion on HHS' fiscal year 1996 combined
financial statements primarily because of (1) a lack of adequate
supporting documentation for $18.3 billion in Medicare Accounts
Payable, $2.7 billion in Medicare Accounts Receivable, $22.6 billion
in Net Position balances, and $3.1 billion in Pension Liability and
(2) difficulty in determining what, if any, adjustments needed to be
made to the Medicare cost settlements reported in the fiscal year
1996 financial statements. 

The fiscal year 1996 financial statement audit identified additional
material internal control weaknesses.  HCFA has no method for
estimating the national error rate for improper Medicare
fee-for-service payments, which the IG estimated at $23 billion for
fiscal year 1996.  HHS lacks important internal controls for grant
management, including the abilities to accrue grant expenditures at
year's end and to track the audits of grantees required by the Single
Audit Act of 1984.  Some operating divisions, including HCFA and NIH,
have weaknesses in the general controls of their electronic data
processing (EDP) systems.  These EDP controls are critical to
ensuring the reliability, confidentiality, and availability of HHS
data and affect the integrity of transactions processed at HHS data
processing facilities, including $206 billion in insurance claims and
indemnities provided to more than 38 million Medicare beneficiaries
in fiscal year 1996.  In addition, the IG identified systemic
weaknesses in controls for estimating and processing transactions
that affect accounts payable and receivable. 


   CONCLUSIONS
---------------------------------------------------------- Chapter 0:5

Considering the magnitude of HHS' responsibilities, the size of its
budget, and the extent to which the American people rely on HHS for
essential services and support, we believe it is critical for the
Department to focus on achieving its many missions as effectively and
efficiently as possible.  Although HHS' commitment to carrying out
its missions is clear, we and others continue to find many problems
with HHS' programs.  The Results Act now provides HHS with an
excellent opportunity to direct its management toward producing its
programs' intended results and to engage in regular self-assessment. 
Specifically, the Department needs to

  -- ensure coordination among its own agencies and with its public
     and private partners;

  -- develop the information systems it needs to manage its programs
     and report on their progress; and

  -- maintain the integrity of programs vulnerable to exploitation by
     remaining vigilant against fraud, waste, abuse, and
     mismanagement. 

As you are aware, we worked with the Congress as it conducted its
reviews of draft and final HHS strategic plans and have already
committed to working with the Congress as it conducts its review of
HHS' performance plan and other submissions under the Results Act. 
As we review HHS' performance plan, we will assess the degree to
which the plan addresses the long-standing management challenges I
have discussed today. 


-------------------------------------------------------- Chapter 0:5.1

Mr.  Chairman, this concludes my prepared statement.  I will be happy
to answer any questions that you or members of the Subcommittee may
have. 

RELATED GAO PRODUCTS

Medicare:  Effective Implementation of New Legislation Is Key to
Reducing Fraud and Abuse (GAO/HEHS-98-59R, Dec.  3, 1997). 

Medicare Fraud and Abuse:  Summary and Analysis of Reforms in the
Health Insurance Portability and Accountability Act of 1996 and the
Balanced Budget Act of 1997 (GAO/HEHS-98-18R, Oct.  9, 1997). 

Medicare Automated Systems:  Weaknesses in Managing Information
Technology Hinder Fight Against Fraud and Abuse (GAO/T-AIMD-97-176,
Sept.  29, 1997). 

Medicare Home Health Agencies:  Certification Process Is Ineffective
in Excluding Problem Agencies (GAO/T-HEHS-97-180, July 28, 1997). 

Child Protective Services:  Complex Challenges Require New Strategies
(GAO/HEHS-97-115, July 21, 1997). 

Medicare:  Problems Affecting HCFA's Ability to Set Appropriate
Reimbursement Rates for Medical Equipment and Supplies
(GAO/HEHS-97-157R, June 17, 1997). 

Medicare:  Need to Hold Home Health Agencies More Accountable for
Inappropriate Billings (GAO/HEHS-97-108, June 13, 1997). 

Medicare Managed Care:  HMO Rates, Other Factors Create Uneven
Availability of Benefits (GAO/HEHS-97-133, May 19, 1997). 

Medicaid Managed Care:  Challenge of Holding Plans Accountable
Requires Greater State Effort (GAO/HEHS-97-86, May 16, 1997). 

Medicare:  Inherent Program Risks and Management Challenges Require
Continued Federal Attention (GAO/T-HEHS-97-89, Mar.  4, 1997). 

Public Health:  A Health Status Indicator for Targeting Federal Aid
to States (GAO/HEHS-97-13, Nov.  13, 1996). 

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


*** End of document. ***