lJnitr!d States Gerrc~ral Accountina Office GAO Report to the Secretary of Health and Human Services August. I!)!)0 I DISABILITY PROGRAMS Use of Competitive Contracts for Consultative Medical Exams Can Save Millions 142035 GA0/HRD90-141 united states CiAO General Accounting Office Washington, D.C. 20648 Human Resources Division B-237482 August 17,199O The Honorable Louis W. Sullivan, M.D. The Secretary of Health and Human Services Dear Mr. Secretary: We reviewed the procurement of medical examinations of claimants seeking benefits under the Social Security Administration’s (SSA’S)disa- bility programs. These consultative examinations (CES) are purchased when claimants’ medical evidence is insufficient for disability determi- nations. State disability determination services (DDSS), who are reim- bursed by SSAfor 100 percent of their CE costs, select medical providers to perform these examinations and determine CE payment amounts.1 New York and Oregon DDS data show substantial savings in CE costs through the use of competitively awarded contracts. We believe that SSA should work closely with other DDSS to identify areas where competi- tively awarded contracts are feasible and to require their use, where appropriate, because of the potential for annual savings of millions of dollars. Consultative medical examinations are purchased by state DDSS who Background make disability determinations on behalf of SSAfor two national pro- grams-social Security Disability Insurance and Supplemental Security Income. In 1989, federal payments for the two disability programs were over $31 billion. As of September 1989, about 7.1 million disabled indi- viduals and their families received benefits from the two programs. As part of the adjudicative process for determining disability, DDSS obtain medical evidence from claimants’ treating sources (attending physicians, hospitals, or other sources of record); but when the informa- tion is unavailable or insufficient, DDSS must purchase a consultative examination. CES include physical and mental examinations, X rays and other diagnostic procedures, and laboratory tests. DDSS purchase CES from three provider groups: (1) individual physicians and psychologists; (2) health care facilities, such as group practices, clinics, and hospitals; and (3) providers that specialize in performing CES. ’ SSA officials said that a proposed regulation clarifies the existing policy for DDSs to attempt to obtain all necessary medical evidence from claimants’ treating physicians. Only when they cannot or will not provide sufficient medical evidence should the DDS purchase CEs from other medical sources, including those awarded competitive contracts. Only a small percentage of CESare pur- chased from claimants’ treating physicians, SSA officials said. Page 1 GAO/HRD-SO-141 DDSs’Use of Competitive Contracts for CES .J B-237482 DDSS are responsible for informing their medical communities about disa- bility program requirements and how to participate in providing CES. They also must recruit and maintain a sufficient number of medical providers to meet their CE needs. DDSS select providers to perform CES from a listing of these providers.* DDSS are also responsible for deter- mining the amounts paid for CES. In fiscal year 1989, SSA reimbursed DDSS about $12 1 million for their costs in purchasing CES. Most states use fee schedules in determining physicians’ reimbursement, although some states reimburse based on physicians’ usual and cus- tomary charges. The reasonableness of state-determined fee schedules was questioned in a 1988 report by the Department of Health and Human Services’ (HHS'S) Inspector General. Based on a comparison of DDS fees across the country, the Inspector General identified wide varia- tions among states (see app. I). Some of the variation was due to medical market and cost-of-living differences. SSAsuggested that state-imposed constraints on DDS fees and rate-methodology differences also accounted for some of the variation. The primary objective of this review was to determine the feasibility of Objectives, Scope,and using competitively awarded contracts to reduce CEexpenditures. Methodology We reviewed legislation, regulations, operating manuals, and other information pertaining to the purchase of CES, as well as prior studies, such as a 1988 HHS Inspector General audit report and an SSA- contracted study. We visited the New York and Oregon DDSSwho use competitively awarded contracts and discussed their cost savings, rea- sons for such contracting, and approaches to contracting. We obtained the cost-savings estimates of the two DDSSand discussed the method- ology used, but did not verify the accuracy of the estimates. We reviewed a “model” contract that SSAhad sent to DDSSin January 1990 for their comment and use in contracting with volume providers for CES." SSA did not provide us the DDS comments until June 1990.4 Con- sequently, during our review we contacted four DDSSthat were not using ‘The listing of medical providers from which DDSs make their CE selections is often referred to as a CE panel. “Providers who receive over $100,000 annually for performing CEss are generally referred to as volume providers. 40ur preliminary review of the DDS comments indicated that the concerns expressed by the DDSs would not alter our conclusions and recommendations. Page 2 GAO/HRD-90-141DDSs’Use of Competitive Contracts for CEs B-227482 competitive contracts to obtain their views on contracting in general and on SSA’Smodel contract specifically. To determine providers’ views on contracting, we talked to all providers in New York who had been awarded a competitive contract and a judgmental sample of such prov- iders in Oregon. Our work was performed at S&A’scentral office in Baltimore. We also contacted SSA regional offices in New York City, Philadelphia, and Seattle. We visited DDS locations in New York, Oregon, Maryland, Penn- sylvania, and Ohio and contacted the Florida DDS. We chose the New York and Oregon DDSS because they were identified by SSA as realizing significant cost savings by using competitively awarded contracts for CE purchases. The other four DDSS were chosen based on their total CE costs. In fiscal year 1989, the DDSS contacted accounted for about 25 percent of total CE expenditures. We discussed SSA’Sposition on a draft of this report with agency offi- cials and incorporated their comments where appropriate. We per- formed our audit work between September 1989 and March 1990 in accordance with generally accepted government auditing standards. The use of competitively awarded contracts for CE purchases by the Cost Savings by New York and Oregon DDSS shows that substantial cost savings are pos- Use of Competitively sible. The New York DDS began competitive contracting for CES in 1986 Awarded Contracts and expects a savings of about $8.3 million over the 3-year life of its contracts.” These savings represent about 26 percent of an estimated $32 million that would have been spent based on the DDS’S fee-schedule amounts. (Examples of New York cost savings for specific types of CES are shown in app. II.) The Oregon DDS, which began using competitive contracts for CE purchases in 1984, expects to save about $1.6 million through 1993. These savings represent about 42 percent of an estimated $3.7 million that would have been spent in the absence of contracts.” Examples of “Excluded from these savings is a g-year statewide contract for laboratory services, which was extended for 2 years in September 1989. For the initial 3-year period, the New York DDS estimated that the contract resulted in annual cost savings of about $60,000 or a SO-percentreduction from the DDS’s fee schedule for such services. “Since the Oregon DDS does not use a fee schedule, the savings represent the difference between the contract prices and the average of physicians’ usual and customary charges for the same services within the geographic areas of the contracts. Page 3 GAO/~90-141 DDSs’Use of Competitive Contracts for CEs , B237482 cost savings for specific types of CES range from 11 percent for ortho- pedic examinations to 79 percent for pulmonary studies. For the 3-year period ending September 30, 1989, the cost savings claimed by the Oregon and New York DDSSwere about 14 and 15 per- cent, respectively, of their total CE expenditures. To obtain this level of cost savings, the two DDSSused competitive contracts for about 50 and 76 percent, respectively, of their total CE requirements. Since, nation- wide, DDSSspent about $121 million for CES in fiscal year 1989, the wide- spread use of competitively awarded contracts has the potential for substantial program savings. Savings by other DDSSwould depend on the portion of their CE purchases obtained by using competitive contracts. Such a portion could be affected by the extent to which DDSSare able to increase their use of medical evidence from claimants’ treating sources and decrease their purchases of medical evidence from other providers. Another factor that could affect the amount of savings would be the extent to which DDSScan obtain reductions below their established fees. The New York and Oregon DDSStold us that savings from competitive contracting were realized with minimal administrative costs. DDS expenditures included the costs of advertising, postage, and travel. The two DDSSrelied on their existing staff for most of their contracting needs. Some assistance was also provided on legal and procurement mat- ters by other branches of their state governments. DDS officials said that staff may need to be dedicated to the project initially because of the amount of work involved during the contract design and execution. New York and Oregon The New York and Oregon DDSShad different motivations for deciding to DDSs’ Reasons; for use competitively awarded contracts. The New York DDS contracted because it was faced with an increasing number of volume providers on Contracting its CE panel. The Oregon DDS was motivated by the need to gain control over escalating medical costs within the state. Historically, the New York DDS has used volume providers for the majority of its CE referrals. Over time, DDs officials said the number of volume providers on the CE panel continued to grow. The growth was attributed to a policy of allowing all capable providers access to the panel. However, as the number of volume providers on the panel grew, the share of referrals available to each provider decreased resulting in some of the providers accusing the DDS of favoritism. Thus, the DDS Page4 GAO/HRD-9Q-141DDSs'UseofCbmpetitiveContracbforCEe decided to use competitive contracts with volume providers in order to eliminate the appearance of favoritism, reduce costs, and improve pro- vider monitoring. The New York DDS selected seven volume providers to perform examina- tions in nine geographic areas. These areas included the New York City metropolitan area and surrounding counties, areas with concentrations of volume providers. Three of the providers were solely in the business of performing CES, two were hospitals, and two were clinics. All had pre- viously been on New York’s CE panel. However, before the use of com- petitive contracts, they had charged the maximum fee-schedule amounts for the services provided, DDS officials said. (Information on the New York DDS'S contract providers is shown in app. III.) The primary reason the Oregon DDS decided to use competitive contracts was to save money. Because the Oregon DDS generally reimbursed based on physicians’ usual and customary charges, DDS officials said there was little control over prices. Thus, to gain price stability and to better budget for medical costs, the Oregon DDS decided to contract competi- tively with providers. As shown in appendix IV, Oregon currently has 33 such contracts in six geographic areas of the state. These areas have a high need for specific medical services and a corresponding high con- centration of specialists needed to perform the necessary CES. Most of the Oregon DDS'S competitive-contract providers are individual and group practices, although there are three hospitals and two clinics. Of the 33 contract providers, one was a volume provider. ReasonsMedical Providers CE providers gave us various reasons for wanting to enter into competi- tively awarded contracts with DDSS.The most important perhaps is the Contract expectation of a steady number of CE referrals. These providers may range from those supplementing a new private practice to those sup- porting a million-dollar organization created solely for performing CES. In exchange for a number of referrals, providers agree to perform CES at a reduced fee. Further, regardless of provider size, the availability of existing staff, equipment, and facility necessary to support the contract are major considerations in the contracting decision. In particular, hospi- tals and clinics may have excess capacity and be eager to contract for CES to utilize this excess. Page 5 GAO/HRD-90-141DDSs’Use of Competitive Contracts for CEs Some of the New York and Oregon DDS competitive-contract providers said they were also providing medical services similar to CES under com- petitive contract with other private and public sources. Thus, they were used to entering into such contracts with clients. New York and Oregon ss~ requires neither that DOSSuse competitively awarded contracts nor DDSs’Approach to that they follow federal acquisition regulations to purchase CES.Thus, to contract for CES, the New York and Oregon DOSSused the procurement Contracting policies and practices of their state governments. The DDS officials said they (1) asked their CE panel members if they were interested in con- tracting, (2) advertised in newspapers and professional journals, and (3) made mass distributions of information. The terms and conditions of their contracts were specified in bid proposals, which also required bid- ders to submit a unit price for each specified type of CE examination, procedure, or test listed. Included in the proposals was an estimate of the number of expected purchases for each type of CE. However, none of the estimates were guaranteed by the DDSS. The DDSSestablished the relative importance to assign to quality and price in the selection of successful bidders. For example, the New York DDS evaluation approach called for excluding bidders that did not meet minimum qualifications and then ranking the remaining bidders by assigning relative weights to quality factors. From the highest ranked bidders, DDS officials said that final selections were made based on the lowest bid prices. Quality factors included physician and staff qualifica- tions, facility and equipment specifications, and reporting standards. Because the competitive-contract providers agreed to perform CES at a reduced price, the DDSSestablished guidelines that gave these providers preference, after the claimants’ treating sources, for CE referrals. Never- theless, the guidelines allowed for continued CE referrals to other prov- iders. The New York DDS, for example, established guidelines to give 80 percent of its CE referrals within the competitive-contract area to con- tract providers and 20 percent to other panel providers. Maintaining relationships with and continuing CE referrals to these other providers allows for flexibility and helps keep future options open. Other Benefits of Besides cost savings, officials in both DDSSmaintain that the use of com- Competitively Awarded petitively awarded contracts resulted in improving the overall quality of the CE services. They said that report quality and timeliness were better Contracts from competitive-contract providers. The competitive selection process Page0 GAO/HRD-QQ-141DDSs'UseofCompetitiveContractsforCEs helps to ensure that better CE providers are awarded contracts. These contract providers generally have more knowledge of and experience with program requirements than panel members who perform CES infre- quently. Also, the contract providers should have a better idea of what is expected of them because expectations are formalized in the contract. The officials also suggested that competitively awarded contracts better assure public accountability and provide for equity and openness in the selection process. Contracts can incorporate specific requirements for staff qualifications and standards for reporting and processing time.7 In May 1987, %A solicited proposals for a study of DDS operations, SSAActions to including the use of volume providers. The study resulted in a January Encourage Contracting 1989 report, which suggested that SSAdevelop a model contract for DDS use in contracting with volume providers.B The use of contracts was shown to improve overall quality and result in substantial cost savings, the report stated. Except in unusual circumstances, it was suggested that contracts be competitively awarded. By obtaining discounts from existing volume providers, savings of from 10 to 26 percent below DDS fee schedules were possible, the report stated. The study found that the nns/volume provider relationships were “informal and non-contractual.” Despite such providers receiving sub- stantial payments for performing CES, the DDSS obtained little or no financial advantage. In most situations that the study reviewed, the volume providers had a history of prior relationships with SSA, including several that involved physicians who had previously worked for ss~. The report suggested that these prior relationships gave the volume providers a better background on SSArequirements. The report also suggested that substantial fee reductions obtained in the private sector from “preferred providers” offer a precedent for DDSS to obtain similar reductions when purchasing CES. Many health insurance companies and self-insured corporations use contracts for purchasing medical services. In contrast to the traditional fee-for-service health plans, private companies contract with a network of physicians who 7To offset possible negative perceptions of volume providers, the New York DDS also contracted with a peer review organization to perform independent quality reviews of its contractors. For fiscal years 1988 and 1989, the cost of peer reviews was about $126,000. “In a prior report SSA Consultative Medical Examination Process Improved: Some Problems Remain (GAO/HRD-86-23, Dec. 10,1986), we determined that about one-half of the states used volume prov- iders, who received about 26 percent of their CE expenditures. Page 7 GAO/HRD-90-141DDSs’Use of Competitive Contracts for CEe B-237432 typically agree to charge the company less than what they usually charge in exchange for an increased patient load and improved cash flow. In January 1990, %A sent a model contract to DDSSfor their guidance and use and “urged” DDSSwho use or plan to use volume providers to obtain financial concessions from them. ss~ is in the process of devel- oping guidelines for contracting and will review DDE replies on the use of the model contract as input to any policy changes. The model contract (similar to the New York DDS volume-provider con- tracts) was written primarily to provide guidance to DDSSfor contracts with large-volume providers who specialize in performing CES. It con- tains an extensive list of “mandatory” medical services to be performed by the selected contractor. Included on the list are over 10 types of spe- cialty examinations and a multitude of related procedures and tests. The model suggests that each proposal should include a fee for each medical service listed as well as documentation to support expected personnel, equipment, and facility costs and expected profit. The four DDSSnot using competitive contracts that we contacted were concerned about their ability to locate qualified providers who could meet all the requirements called for in SSA’Smodel contract, One concern was that few medical markets would have providers capable of per- forming the number of mandatory examinations and other medical ser- vices listed in the model contract. Without an adequate number of providers willing to compete, it may not be possible to obtain the same discounts available in a competitive market. It was suggested that the model contract would most likely not apply to individual physicians and group practices because of the required multiple specialties. Also, use of the model contract may discourage some providers because of its exten- sive requirements and the amount of information to be submitted. In addition, one of the DDSSwas concerned that emphasis on large volume, as suggested by SSA, may create an undesirable situation of over reliance on one or a few providers for most CE needs. In contrast to the model contract approach, the DDSSsuggested to us that the contract approach used by the Oregon DDS would probably be more suitable to the circumstances of many DDSS.The contracts used by the Oregon DDS contain fewer requirements and are generally based on a smaller number of CE referrals with individual physicians and group practices that offer one or a limited number of specialties. Page 8 GAO/IKRIM@141DDW Use of Competitive Contracts for CES 5237432 To decide whether to contract competitively for CES, DDSSneed to eval- SuggestedApproach uate their individual circumstances. Steps that DDSScould take include: to Determine (1) targeting geographic areas within the state with concentrations of Feasibility for claimants and providers, (2) determining CE needs in targeted areas, (3) matching CE needs with the types of specialists available in targeted Competitive Contracts areas, and (4) obtaining a preliminary indication of provider willingness to bid at a discounted price in exchange for some or most of the expected CE referrals in target areas. At this point, the DDS may wish to pilot test the concept by using competitive contracting only within a selected area. To encourage maximum competition, the DDS could contact existing panel members and other providers in the targeted areas as well as advertise in newspapers and professional journals. Even if the overall state fee schedule is low, it may still be possible to obtain discounts from individual specialists in certain geographic areas. It may be possible to competitively contract below the DDS fee schedule in areas with high concentrations of one or more specialists. Hospitals and clinics were shown by the New York and Oregon DDSSto be good sources for competitive CE contracts because of underutilized test equip- ment and excess facility capacity. Competitively awarded contracts can be effective in reducing the costs Conclusions of CES. Relying on marketplace forces provides better assurance of the reasonableness of prices. The competitive selection process can also help to ensure that the better CE providers are awarded contracts. Such con- tracts can further be used to better communicate expectations and to build in higher standards for quality, timeliness, and other requirements. The contracting experience of the New York and Oregon DDSSdemon- strates the benefits that can be derived from introducing greater compe- tition into the provider selection process. Nevertheless, we realize that competitively awarded contracts may not always be applicable because of a low fee schedule or insufficient competition. Furthermore, some DDSSmay experience higher administrative expenses for contracting than the New York and Oregon DDSS,especially if it is necessary to hire additional staff. SSA’Smodel contract is designed primarily for states that use large- volume providers. Some of these states may find it impractical to use competitive contracts with their volume providers. For such states and for states that do not use volume providers, we believe that ss~, in Page 9 GAO/HRD-90-141DDSs’Use of Competitive Contracts for CES B-237432 developing guidelines for contracting, should incorporate provisions for the use of competitive contracts suitable for providers that offer one or a limited number of specialties. We believe such provisions would be more suitable for the individual and group-practice providers in DDS medical markets and lead to more widespread use of competitively awarded contracts. We recommend that you direct the Commissioner of ss~ to: Recommendations 1. Require DDSSto periodically determine the feasibility of using com- petitively awarded contracts. 2. Require SSA’S disability program managers to work closely with DDSS to determine contract feasibility and to provide assistance as needed. %A should ensure that DDSSuse competitively awarded contracts where feasible. 3. In developing guidelines for competitive contracting, include provi- sions suitable for contracts with individual and group practices. As you know, 31 USC. 720 requires the head of a federal agency to submit a written statement on actions taken on our recommendations to the House Committee on Government Operations and the Senate Com- mittee on Governmental Affairs not later than 60 days after the date of the report and to the House and Senate Committees on Appropriations with the agency’s first request for appropriations made more than 60 days after the date of the report. Copies of this report are being sent to interested congressional commit- tees and subcommittees; the Director, Office of Management and Budget; and other interested parties. Copies will also be made available to others on request. Page 10 GAO/HRD-90-141DDSs’Use of Competitive Contracta for CES .I” 5287482 Please contact me at (202) 276-6193 if you or your staff have any ques- tions concerning this report. Other major contributors to this report are listed in appendix V. Sincerely yours, pm@?9 Joseph F. Delfico Director, Income Security Issues Page 11 GAO/HlZD-fJO-141 DDSs’Use of Competitive Contracts for CEs Contents Letter Appendix I Comparison of DDS Feesfor Selected Types of Consultative Examinations Appendix II 16 New York DDS 1989 Cost Savings: Comparison of Fee Schedule and Contract Fees Appendix III 16 New York DDS Consultative Examination Contracts Appendix IV 17 Oregon DDS Consultative Examination Contracts Major Contributors to 18 This Report Page 12 GAO/HRD9@141 DDW Use of Competitive Contracts for CJk Contenta Abbreviations CE consultative examination DDS disability determination service GAO General Accounting Office HHS Department of Health and Human Services SSA Social Security Administration Page 13 GAO/HR.D&O-141 DDSs’ Use of Competitive Contracts for Cl% Appendix I 1 Comparisonof DDSFeesfor SelectedTypes of Consultative Examinations DDS feesa Selected CEs Hiah DDS Low DDS Averaae Examinations Internal medicine $120 $70 $85 Cardiology 120 70 86 Psvchiatrv 120 70 90 Orthopedic 120 70 86 Diaonostic orocedures Chest X rav 100 22 45 EKG 103 25 42 Doppler (resting) 200 60 103 Doppler (exercise) 412 45 147 Stress test-treadmill 400 74 162 Laboratory tests Urinalysis 15 4 4 Blood sugar 28 4 IO Creatinine 29 5 11 Complete blood count 40 6 17 ANA 44 15 26 Sed rate 44 4 10 SMA 12 35 9 22 aln commenting on a draft of this report, SSA officials said that this comparison was based on a review of 12 of the 52 DDSs. SSA also provided a 1990 comparison based on the fees of all 52 DDSs that showed wider variations for some of the selected CEs. Source: Disability Determination Services Medical Evidence Development Best Practices and Improve- ment Optrons, HHS Office of the Inspector General, August 1988. Page 14 GAO/HRBBO-141 DDSs’ Use of Competitive Contracts for CEe Appkhdix II New York DDS 1989 Cqt Savings:Comparison of FeeScheduleand Contract Fees Fee Percent Selected CEs schedulea Contf~~ savings Examinations Comprehensive drua addition $164 $106 35 Complete ear (with baranv or caloric) 118 68 42 Complete neurological 82 53 35 Complete orthopedic 82 53 35 Complete psvchiatric 82 53 35 Intelligence evaluation 67 45 33 Personality evaluation 107 70 35 Personalitv and oraanicitv evaluation 134 80 40 Diagnostic procedure Ventilation tests 38 23 39 Electrocardiogram, resting 56 22 61 Electroenceohaloaram (EEG) 140 98 30 Electromyography (EMG) 2 extremities and related paraspinol area 253 114 55 Treadmill exercise electrocardiography 211 132 37 Speech discrimination test binaurel 42 16 62 X ray, skull, complete 135 81 40 X ray, ribs, both sides 113 44 61 X rav. chest. sinale PA 45 27 40 X ray, spine, cervical, minimum of 4 views 113 68 40 Doppler ultrasound flow meter test, bilateral, arterial only 71 43 39 Doppler utlrasound flow meter test after exercise, arterial only 91 53 42 aThe New York DDS uses fees from the state workers’ compensation program Page 16 GAO/HRD-90-141 DDSs’ Use of Competitive Contracts for CEs 7 Appendix III Yi New York DDSConsultative Examination Conlmxts Estimated Geographical 1889 ContractoP area obligations Diaanostic Health Services Manhattan $959.646 Health Disabilitv Consultina Services, Inc. Manhattan 1,008,210 Brooklyn Hospital Brooklyn 1,595,947 K-MD Management Services, Inc. Brooklyn 1,742,368 K-MD Manaaement Services, Inc Bronx 778.903 Union Hospital of the Bronx Bronx 1,182,169 New York Diagnostic Centers Queens 995,674 North Broadway Medical Associates Nassau County 343,160 North Broadwav Medical Associates Suffolk Countv 558,108 Total $9,164,185 Average $1,018,243 aEach contractor performs several types of specialty examinations and diagnostic procedures. bAll of the contracts are within metropolitan New York City and the surrounding counties. Page 16 GAO/HRBBO-141 DDSs’ Use of Competitive Contracts for CEs Appendix IV oiregonDDSConsultative Emmination Contracts Number of Estimated 1989 Specialty type of CEO Contract locationsb contracts obligations Rheumatology Portland 1 $42,000 Orthopedics Portland 1 200,000 Pulmonary Portland 1 20,000 Springfield 1 15,000 Medford 1 7,000 Cardiology Portland 1 70,000 Springfield 1 15,000 Medford 1 18,000 Neurology Portland 1 25,000 Mental Albany 3 34,000 Ashland 2 20,500 Corvallis 2 9,500 Eugene 3 70,500 Medford 3 / 36,500 Portland 7 141,500 Salem 3 81,000 Springfield 1 24,000 Totals 33 $829.500 Averaae $2&l 36 %cludes both specialty examination and any necessary diagnostic procedure and laboratory test. ‘Populations in geographic areas covered by contracts include: Portland, 1,092,OOO; Medford/Ashland, 141,700;Corvallis, 69,100; Salem/Kaiser, 255,000; Albany, 89,900; and Eugene/Springfield, 273,700. Page 17 GAO/HRD-90-141 DDSs’ Use of Competitive Contracts for CEs , , . Major Contributors to This Report Barry D. Tice, Assistant Director, (301) 96643920 Human Resources William E. Hutchinson, Evaluator-in-Charge Division, Edith J. Byrne, Evaluator Washington, DC. (105845) Page 18 GAO/HRDW141 DJXW Use of Competklve Contracta for C& Official Hlisiwss I Permit No. GlOO I
Disability Programs: Use of Competitive Contracts for Consultative Medical Exams Can Save Millions
Published by the Government Accountability Office on 1990-08-17.
Below is a raw (and likely hideous) rendition of the original report. (PDF)