oversight

Aging Issues: Related GAO Reports and Activities in Fiscal Year 1989

Published by the Government Accountability Office on 1990-01-12.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

        united
             states
        General Accounting Office
        Washington, D.C. 20648

        Human Resources Division

        B-217196
        January 12,lDDO

        The Honorable David H. Pryor
        Chairman, Special Committee I
           on Aging
        United States Senate
        Dear Mr. Chairman:

        This report is in responseto the Committee’s October 11, 1989, request-
        for a compilation of our fiscal year 1989 activities regarding older
        Americans.
          _..ll.^*.....l,ll
                      ..10.
        Our work covered a broad range of issues,including -~l-.“~“.l.*
                                                            income““1  security,
        health care, housing, nut&ion, social, community and legal services,
        employment and age~discrimination.Someof the federal   ...”policies that
        addressthese issuesare directed solely or primarily to the elderly, such
        m.&$al.Security and Medicare. Other federal policies target the elderly
        as one of several groups served by a program or funding mechanism,
        such as social services~,block
                                     grants or Medicaid.
        In the appendixes, we describe five types of GAO activities that relate to
        older Americans:

    . Reports on policies and programs directed primarily at older Americans
      (see app. I).
    l Reports on policies and programs in which the elderly were one of sev-
      eral target groups (see app. II).
    9 Testimonies on issuesrelated to older Americans (see app. III).
    l Ongoing activities on issuesrelated to older Americans (see app. IV).
    . Other activities by GAO officials, such as speaking engagementsand pub-
      lications, on issuesrelated to older Americans (see app. V).
        These products and activities and the issuesaddressedare presented in
        table 1. The table shows that income security was the leading issue
        among activities directed primarily at the elderly, while health was the
        leading issue acrossall types of activities and products.
        Appendix I lists 69 issued reports on policies and programs directed pri-
        marily at the elderly (seetable 1). We include in this section reviews of
        income security, health, social and other services,housing and veterans
Y
        issues.We also describe GAO'S managementreviews of the agenciesdeal-
        ing with the elderly, as well as reports on the infrastructures of such
        agencies,including their computer systems.These aspectsof agency


        Page1                               GA0/HRD-90-60AgingIssuesinFiecdYear1989
                                                     operations determine how well agenciescan implement policies relating
                                                     to the elderly.




                                          Reporta
   bie 1: GAO Actlvltier     Relating to the Elderly In Flrcal Year 1999
                                                                                          Type of activity
                                                                    Report8 with
                                                                elderly aa one of                                            Ongoing
                                      focuwd on                    several target                                        activities as                 Other
                                       the elderly                        groups                  Tebtimonv                of 9130189             activities0
                                                25                                 4                           11                   31                     17
                                                21                                 7                           10                   48                     18
                                                12b                                5b                           2b                  20b                     0
  ociai and other services                       0                                 8                            2                   11                      2
                                                 0                                 4                            1                    3                      1
@her                                             1                                 0                            0                    1                      1
‘iiotal
  +                                            s9                                28                           26                   114                     39
                                                     %cludes   speaking engagements      and publications.
                                                     blncludes veterans’ health issues


                                                    Appndix II describes28 reports in which the elderly were one of sev-
                                                         target groups for specific federal policies. With the exception of
                                                         r Americans Act programs, social and other services are generally
                                                          ted in conjunction with servicesto other populations. For example,
                                                    block grants fund community servicesor energy assistancefor the eld-
                                                    erly, as well as servicesfor other age groups; Medicaid finances nursing
                                                    home care, as well as medical care for poor people of all ages;and Native
                                                    American programs fund social and health services for Native American
                                                    elderly, as well as programs for other Native Americans. We also
                                                    describe two transition reports, which are broad policy overviews of
                                                    health and human services and housing.
                                                    Appendix III describesthe 26 testimonies given in fiscal year 1989 on
                                                    subjects focused primarily on older Americans. We testified more times
                                                    on income security than any other issue.
                                                    In appendix IV we have listed the 114 studies directly related to older
                                                    Americans that were ongoing as of September30, 1989. As table 1
                                                    shows, we are increasing our activities on all issuesrelating to the
                                                    elderly.
                                                    In addition to reports and testimonies, GAO officials are called upon to
                                                    appear on news interviews and professional and academicpanels, as


                                                    Page 2                                                   GAO/HUD-SO-66   Aging Issues in Fiscal Year 1989
    well as to publish on topics for which they have particular expertise.
    Appendix V describesthe 39 times GAO officials spoke or published on
    aging issues.
    You also asked for information on our employment of older Americans.
    Our policies prohibit age discrimination (see app. VI), On September30,
    1989,64 percent of our work force was 40 years of age or older. We
    continue to provide individual retirement counseling and group prere-
    tirement seminars.
    As arranged with your office, we are sending copiesof this report to
    interested congressionalcommittees and subcommittees.Copies also will
    be available to others on request.
    This report was prepared under the direction of Joseph F. Delfico, Direc-
    tor, Income Security Issues.Should you have any questions concerning
    this report, please call him on (202) 275-6193.Other major contributors
    are listed in appendix VII.
    Sincerely yours,




    Lawrence H. Thompson
    Assistant Comptroller General




w




    Page 3                             GAO/HRD-90-66   Aging Issues in Fiscal Year 1989
Ckmtents


wt er                                                                                                  1

   ppendix I                                                                                         12
  iscal Year 1989 GAO   Health
                         Board and Care: Insufficient AssurancesThat Residents’
                                                                                                     12
                                                                                                     12
  eports on Issues           NeedsAre Identified and Met (GAO/HRD-89-50,Feb.
i rimarily Affecting         10,1989)
                         Health Insurance: Bibliography of Studies on Health                          13
4 lder Americans             Benefits for the Uninsured (GAO/HRD-89-27FS,Feb.
                             24,1989)
                         Information Technology: Health Care Financing                               13
                             Administration’s Budget ProcessNeedsImprovement
                             (GAOIIMTEC-89-31, Aug. 11, 1989)
                         Internal Controls: Need to Strengthen Controls Over                         13
                             Payments by Medicare Intermediaries (GAO/HRD-89-
                             8, Nov. 14, 1988)
                         Long-Term Care for the Elderly: Issuesof Need, Access,                      14
                             and Costs (GAO/HRD-89-4,Nov. 28,1988)
                         Long-Term Care Insurance: State Regulatory                                  14
                             Requirements Provide Inconsistent Consumer
                             Protection (GAO/HRD-89-67,Apr. 24, 1989)
                         Medicaid: RecoveriesFrom Nursing Home Residents’                            15
                             Estates Could Offset Program Costs (GAO/HRD-89-
                             66, Mar. 7, 1989)
                         Medicaid: SomeRecipients Neglect to Report U.S.                             15
                             Savings Bond Holdings (GAO/HRD-89-43,Jan. 18,
                             1989)
                        Medicare: An Assessmentof HCFA’s 1988 Hospital                               15
                             Mortality Analyses (GAO/PEMD-89-llBR, Dec. 13,
                             1988)
                        Medicare Catastrophic Act: Options for Changing                              16
                            Financing and Benefits (GAO/HRD-89-166,
                            Sept. 15, 1989)
                        Medicare: Health Maintenance Organization Rate-Setting                       16
                            Issues(GAO/HRD-89-46,Jan. 31,1989)
                        Medicare: Impact of State Mandatory Assignment                               17
                            Programs on Beneficiaries (GAO/HRD-89-128,
                            Sept. 19,1989)
                        Medicare: Incentives Neededto Assure Private Insurers                        17
                            Pay Before Medicare (GAO/HRD-89-19,Nov. 29,
                             1988)



                        Page 4                          GAO/HRD-90-56   Aging Issues in Fiscal Year 1989
 Medicare: Indirect Medical Education Payments Are Too                        17
    High (GAO/HRD-89-33,Jan. 6,1989)
 Medicare: Physician Incentive Payments by Prepaid                            18
    Health Plans Could Lower Quality of Care (GAO/
    HRD-89-29,Dec. 12,1988)
 Medicare: Program Provisions and Payments Discourage                         18
    Hospice Participation (GAO/HRD89-111, Sept. 29,
    1989)
 Medicare PROS:Extreme Variation in Organizational                           18
    Structure and Activities (GAO/PEMD-89-7FS,Nov. 8,
    1988)
 Medicare: Reasonablenessof Health Maintenance                               18
    Organization Payments Not Assured (GAO/HRD-89-
    41, Mar. 7, 1989)
 Medicare: Status Report on Medicare Insured Group                           19
    Demonstration Projects (GAb/HRD-89-64, June 27,
    1989)
 Medicare: Statutory Modifications Neededfor the Peer                        19
    Review Program Monetary Penalty (GAO/HRD-89-
    18, Mar. 30,1989)
 U.S. Employees Health Benefits: Rebate for Duplicate                        20
    Medicare Coverage(GAOIHRD-89-58,Mar. 23, 1989)

Income Security                                                              20
 ADP Budget: SSA’sFiscal Year 1990 Information                               20
    Technology Systems Budget Request(GAO/IMTEC-
    80-60, June 28,1989)
 ADP Planning: SSA’sFebruary 1989 Report on                                  20
    Computer Modernization Is Incomplete (GAO/IMTEC-
    89-76, Sept. 25, 1989)
 ADP Systems:SSAEfforts in Implementing Its Field                            21
    Office Modernization (GAO/IMTEC-89-45,
    May 17,1989)
 Age Discrimination: Use of Waivers by Large Companies                       21
    Offering Exit Incentives to Employees (GAOIHRD-89-
    87, Apr. 18, 1989)
 Computer Operations: Improvements Neededin Social                           21
    Security’s Capacity ManagementProgram (GAO/
    IMTEC-89-8, Jan. 18, 1080)
 District’s Workforce: Annual Report Required by the                         22
    District of Columbia Retirement Reform Act (GAO/
    GGD-89-57,Mar. 22, 1980)



Page 6                          GAO/HRD-99-66   Aging Issues in Fiscal Year 1989
 Employee Benefits: Company Actions to Limit Retiree                          22
     Health Costs(GAO/HRD-89-31BR,Feb. 1,1989)
 Employee Benefits: Companies’ Retiree Health Liabilities                     22
     Large, Advance Funding Costly (GAO/HRD-80-61,
     June 14,1989)
 Federal Employees:Early Retirements at the Defense                           23
     Department in Fiscal Year 1988 (GAO/GGD-80-63FS,
     Feb. 23,1989)
 Federal Retirement: Use of Contractors to Implement the                      23
     Federal Employees Retirement System (GAO/GGD-
     89-29, Feb. 1, 1080)
 Federal Workforce: Positions Eligible for Law                                23
     Enforcement Officer Retirement Benefits (GAO/GGD-
     89-24, Feb. 2, 1080)
 Leveraged Buy-Out Funds: Investments by Selected                             24
     Pension Plans (GAO/HRD-89-121, Aug. 1,1989)
 Pension Plans: Labor and IRS Enforcement of the                              24
     Employee Retirement Income Security Act (GAO/
     HRD-89-32,Jan. 23, 1989)
 Poor Performers: How They Are Identified and Dealt                           24
    With in the Social Security Administration (GAO/
    GGD-89-28,Jan. 27, 1989)
 Private Pensions:Plan Provisions Differ Between Large                        25
     and Small Employers (GAO/HRD-89-105BR,Sept. 26,
     1089)
 Private Pensions:Portability and Preservation of Vested                      25
    Pension Benefits (GAO/HRD-80-lSBR, Feb, 3,1989)
 Railroad Retirement: Future Rail Employment and Trust                        25
    Fund Solvency (GAO/HRD-89-30,Apr. 5, 1980)
 Social Security: Leadership Structure for an Independent                     26
    Social Security Administration (GAO/HRD-89-154,
    Sept. 13, 1989)
 Social Security: Results of Required Reviews of                              26
    Administrative Law Judge Decisions(GAO/HRD-89-
    48BR, June 13,1989)
 Social Security: Staff Reductions and Service Quality                        26
    (GAO/HRD-89-106BR,June 16,1989)
 Social Security: Status and Evaluation of Agency                             27
    ManagementImprovement Initiatives (GAO/HRD-89-
    42, July 24, 1989)
 Social Security: Time Required to Approve and Pay                            27
    Attorney FeesCan Be Reduced(GAO/HRD-89-7,Oct.
    18,1988)


Page 6                            GAO/HRD90-66   Aging Issues in Fiscal Year 1989




                                    ,’
 Social Security: The Trust Fund ReserveAccumulation,                          27
    the Economy, and the Federal Budget (GAOIHRDSO-
    44, Jan. 10,1080)
 Social Security: Views of Agency Personnelon Service                          28
    Quality and Staff Reductions (GAO/HRD-89-3’7BR,
    Feb. 10,198O)
 Software Maintenance: SSA’sUse of Its Software                                28
    Maintenance Package(GAO/IMTEC-89-38,
    June l&1089)
Veterans                                                                       20
 Financial Audit: Veterans Administration’s Financial                          29
    Statements for Fiscal Years 1988 and 1987 (GAO/
    AFMD-80-60, Sept. 16, 1989)
 Financial Management:Opportunities for Improving                              29
    VA’s Internal Accounting Controls and Procedures
    (GAO/AFMD-89-36, Aug. 11,1989)
 VA Benefits: Law Allows Compensation for Disabilities                         29
    Unrelated to Military Service (GAO/HRD-89-60,July
    31,1989)
 VA Health Care: Allegations Concerning VA’s Patient                           30
    Mortality Study (GAO/HRD-80-80,May 18,1989)
 VA Health Care: Delays in Awarding Major Construction                         30
    Contracts (GAOjHRD-89-76,Mar. 31,1089)
 VA Health Care: Few Veterans Denied Care at Florida                           30
    Clinics (GAO/HRD-89-60,May 31,198O)
 VA Health Care: Improvements Neededin Proceduresto                            30
    Assure Physicians Are Qualified (GAO/HRD-80-77,
    Aug. 22,1089)
 VA Health Care: LanguageBarriers Between Providers                            31
    and Patients Have Been Reduced(GAO/HRD-80-40,
    Mar. 8,198O)
 VA Health Care: ResourceAllocation Methodology Has                            31
    Had Little Impact on Medical Centers’ Budgets (GAO/
    HRD-89-03,Aug. 18,198O)
 Veterans’ Benefits: Improvements Neededin Processing                          31
    Disability Claims (GAO/HRD-80-24,June 22,1089)
 Veterans’ Benefits: Improvements Neededto Measure                             32
    the Extent of Errors in VA Claims Processing(GAO/
    HRD-89-0,Apr. 13, 1980)
 Veterans’ Benefits: Need to Update Medical Criteria                           32
    Used in VA’s Disability Rating Schedule(GAO/HRD-
    80-28, Dec. 29, 1088)


Page 7                           GAO/HRD-96-56   Aging Issues in F’iscal Year 1989
                                                                                            -
                       contents




,
                       Other                                                                           32
                        Aging Issues:Related GAO Reports and Activities in                             32
                           Fiscal Year 1988 (GAO/HRD-89-38,Jan. 26,108O)

ppendix II
‘seal Year 1989 GAO    Health
                        ADP Planning: FDA’s Plans to Improve Processingof
                                                                                                       ii
                                                                                                       33
eports on Issues           Medical Device and Drug Applications (GAO/IMTEC-
ffecting the Elderly

!I
                           89-58, June 13,1989)
                        ADP Systems:Better Control Over States’ Medicaid                               33
 d Others                  SystemsNeeded(GAO/IMTEC-89-10,
                           Aug. 2,1989)
                        Health and Human ServicesIssues(GAO/OCG-89-lOTR,                               34
                           Nov. 1988)
                        Medicaid: Federal Oversight of Kansas Facility for the                         34
                           Retarded Inadequate (GAO/HRD-89-85,Sept. 20,
                           1089)
                        Mental Health: Prevention of Mental Disorders and                              34
                           Researchon Stress-RelatedDisorders (GAO/HRD-80-
                           07, Sept. 12, 1980)
                        Prescription Drugs: Information on SelectedDrug                                35
                           Utilization Review Systems(GAO/PEMD-89-18,
                           May 25,1089)
                        Prescription Drugs: HCFA’s ProposedDrug Utilization                            35
                           Review System Ignores Quality of Care Issues(GAO/
                           PEMD-89-26BR,July 13,1989)
                       Housing                                                                         36
                        Housing and Urban Development Issues(GAO/OGC-80-                               36
                           22TR, Nov. 1988)
                        Housing Conference:National Housing Policy Issues                              36
                           (GAOIRCED-89174, Aug. 1989)
                        Partnership Projects: Federal Support for Public-Private                       36
                           Housing and Development Efforts (GAO/PEMD-80-
                           25FS,Sept. 14,1989)
                        Tax Policy: Costs Associated With Low Income Housing                           37
                           Tax Credit Partnership (GAO/GGD-89-lOOFS,July
                           10,198O)




                       Page 8                            GAO/HRD.~S6   A.&g   Issuea in Fiscal Year 1989



                                                                                         8, “ia.,.‘,
Income Security                                                                37
 Employee Stock Ownership Plans: Allocation of Assets                          37
    in SelectedPlans (GAO/HRD-80-01,June 5,198O)
 Federal Compensation:Premium Taxes Paid by the                                37
    Health Benefits Program (GAO/GGD-89-102,Aug. 8,
    1989)
 Social Security: Selective Face-To-FaceInterviews With                        38
    Disability Claimants Could ReduceAppeals (GAO/
    HRD-89-22,Apr. 20, 1989)

Social and Other Services                                                     38
 Block Grants: Federal-StateCooperation in Developing                         38
    National Data Collection Strategies (GAO/HRD-89-2,
    Nov. 29,1988)
 Community Development: Distribution of Small Cities                           30
    Funds by Pennsylvania (GAO/RCED-89-111,
    May 3,1989)
 Financial Audit: Food and Nutrition Service’s Financial                       30
    Statements for 1087 (GAO/AFMD-80-22, Mar. 15,
    1989)
 Food Stamp Program: Administrative Hindrances to                              39
    Participation (GAO/RCED-89-4,Oct. 2 1, 1988)
 Food Stamp Program: Participants Temporarily                                  40
    Terminated for Procedural Noncompliance(GAO/
    RCED-89-91,June 22,1989)
 Food Stamps: Reasonsfor Nonparticipation (GAO/                                40
    PEMD-89-5BR,Dec. 8, 1088)
 Montana Indian Reservations:Funding of Selected                               40
    Services,Taxation of Real Property (GAO/HRD-89-
    IBR, Oct. 11, 1988)
 Parental Leave: RevisedCost Estimate Reflecting the                           40
    Impact of Spousal Leave (GAO/HRD-89-68,Apr. 6,
    1080)
Veterans                                                                       41
 DefenseHealth Care: Patients’ Views on Care They                              41
    Received(GAO/HRD-80-137,Sept. 13,1989)
 DefenseHealth Care: Workload Reductions at Military                           41
    Hospitals Have Increased CHAMPUSCosts (GAO/
    HRD-89-47,July 10, 1989)
 DOD Heath Care: IssuesInvolving Military Nurse                                42
    Specialists (GAO/HRD-89-20,Mar. 20, 1089)



Page 9                            GAO/HRD-90-86   Aging Issuea In Fiscal Year 1989
                            Contents




                             DOD Health Care: OccurrenceScreenProgram                                    42
                               Undergoing Changes,but WeaknessesStill Exist
                               (GAO/HRD-89-36,Jan. 6,198Q)
                             DODHealth Care: Extent to Which Military Physicians                         43
                               Perform Administrative Tasks (GAO/HRD-89-63,
                               Feb. 13,198Q)

                                                                                                         44
   cal Year 1989 GAO Health                                                                              44
                                                                                                         46
   timony Relating to ~c~~\ecurity                                                                       45
                            Social Services                                                              46
Elderly                     Veterans                                                                     47

4ppendix IV                                                                                              48
Ongoing  GAO Work as Health
OQ September 30, 1989, EcyL\ecurity
                                                                                                         48
                                                                                                         61
                                                                                                         62
IUating to Issues      Social and Other Services                                                         53
Affecting the Elderly  E;Ews                                                                             64
                                                                                                         65

Appendix V                                                                                               66
&her Fiscal Year 1989 Health
                      Housing
                                                                                                         66
                                                                                                         68
Activities by GAO     Income Security                                                                    68
officials Relating to Social Services                                                                    60
Issues Affecting the  Other                                                                              60
Mderly
bppendix VI                                                                                              61
GAO Activities
Affecting Older
Workers
           Y




                            Page 10                         GAO/HRD-90456   Aging Issues in Fiscal Year 1999
        j.
        I
.       I


        I                    Cuntenta




                                                                                                            62
        r Contributors to

                            Table 1: GAO Activities Relating to the Elderly in Fiscal
    I                           Year 1989




                            Abbreviations

                            AAPCC adjusted average per capita cost
                            ACR    adjusted community rate
                            ADP    automated data processing
                            ADL    activities of daily living
                            AU     administrative law judge
                            CHAMPUSCivilian Health and Medical Program of Uniformed             Services
                            DDS    Disability Determination Service
                            DOD    Department of Defense
                            ESOP   employee stock ownership plan
                            FEHBP Federal Employees Health Benefit Plan
                            FERS   Federal Employee Retirement System
                            FDA    Food and Drug Administration
                            GAO    General Accounting Office
                            HCFA   Health Care Financing Administration
                            HHS    Department of Health and Human Services
                            HMO    health maintenance organization
                            HUD    Department of Housing and Urban Development
                            MIG    Medicare Insured Group
                            NIMH   National Institute of Mental Health
                            OPM    Office of PersonnelManagement
                            PRO    peer review organization
                            RAM    resource allocation methodology
                            SW     Statistical Quality Control
                            SSA    Social Security Administration
                            VA     Department of Veterans Affairs


                            Page 11                            GAO/HRD-99456   Aging Issues in Fiscal Year 1989
 .
Appendix I                                                                                                 i
                                                                                                                 fi
Flscal Year 1989 GAO Reportson Issues                                                                             I
P@mrily Affixting Older Americam
                                                                                                                 1,




                            During fiscal year 1989, we issued 69 reports on issuesprimarily affect-
                            ing the elderly. Of these, 26 were on income security, 21 were on health,
                            12 on veterans’ issues(including 6 on veterans’ health care), and 1 on               ”
                            other issues.An asterisk after the report title indicates that the review
                            was performed at the request of Committees or Membersof Congress.
                            Two asterisks indicate that the work was mandated by statute.
    1
    I
Hbalth
-
Bbard and Care:             Many elderly and disabled adults reside in board and care homes; little
Irhfficient Assurances      is known nationally, however, about the residents’ needs,the care they
                            receive, or the total number of homes operating in the United States. In
That Residents’ Needs Are    1976, the Congressenacted the Keys Amendment to the Social Security
Identified and Met (GAO/    Act. The act required states to certify, to the Department of Health and
H/RD-89-50,Feb. 10, 1989)   Human Services(HHS), that all facilities in which a significant number of
                            Supplemental Security Income recipients resided or were likely to reside
                            met appropriate standards. HHSis only required to record that it
                            received the states’ annual certificates concerning compliance. HHShas
                            done little to monitor state actions or sanction states not in compliance.
                            In the six states we visited, the states continue to find serious problems
                            in somelicensed board and care homes.These problems range from very
                            serious situations, such as residents being subjectedto physical and sex-
                            ual abuse,to persistent unsanitary conditions. In somecasesresidents
                            were denied heat, were suffering from dehydration, were denied ade-
                            quate medical care, or had food withheld if they did not work. Situa-
                            tions have occurred that have contributed to the death of board and
                            care residents. HHSneeds(1) to conduct a comprehensiveassessmentof
                            states’ oversight activities for their board and care population and (2)
                            report to the Congressfindings and, if appropriate, recommendations as
                            to further steps neededto assureprotection of residents and changes
                            neededto the Keys Amendment to make it more effective.




                            Page 12                            GAO/HRD-994%   Aging Issues in Fiscal Year 1999
                                   Appendix I
                                   Piecal Year 1989 GAO Reporta on Lssues
                                   PrimarUy M&tfng    Older Americans




                                   This annotated bibliography lists studies concerning health benefits for
       graphy of Studies on the uninsured. It cites literature, including books,journal articles, and
        Benefits for the    research reports published between 1980 and 1988.




  Info mation Technology:         The Health Care Financing Administration’s (HCFA’S) Information Tech-
  Heal‘1h Care Financing          nology System budget request of $73.6 million for fiscal year 1990 may
                                  not accurately and fully estimate automated data processing(ADP)
  Administration’s Budget         expenditures. HCFA’S cost estimate of $22 million for an ADP initiative to
( ProcpssNeeds                    expand system capacity for the Catastrophic CoverageAct of 1988 was
~ Improvement (GAO/               not supported by sufficient analysis becauseHCFA lacked time to make a
  IMTEC-89-31, Aug. 11,           more accurate estimate. Fiscal years 1991-92costs of the PRISMsystem
  1989)*                          have been increased by about $7.2 million. The system is intended to
                                  give HCFA additional ADP and telecommunications capacity to improve
                                  program operations and supply better data to assessthe impact of new
                                  health care proposals. Further, HCFA has not included in its information
                                  technology systems budget request over $947 million included in its pro-
                                  grammatic budget for Medicaid state and Medicare contractor ADP costs
                                  and for a major Medicare project. Although HCFA believes that contrac-
                                  tors can contribute to Medicare ADP cost reduction-by cutting the
                                  number of systems used and trimming maintenance costs through shar-
                                  ing arrangements or adopting a HCFA-compatible system-HCFA believes
                                  that it doesnot have the legal authority to direct system standardization
                                  and consolidation.


 Internal Controls: Need to       HCFAis experiencing problems in   resolving claims processingerrors con-
 Strengthen Controls Over         cerning Medicare payments to institutions and needsto better use the
                                  results of external reviews in managing Medicare. HCFA has not ensured
 Payments by Medicare             that intermediaries resolve potential claims processingerrors identified
 Intermediaries (GAOIHRD-         by master record computer edits. This has resulted in a backlog of over
 89-8, Nov. 14, 1988)             2 million unresolved errors as of July 1987. In reviewing 277 of these
                                  potential errors, GAOfound 73 overpayments totaling $272,011 and 7
                                  underpayments totaling $6,468, GAOprojected that the three peer review
                                  organizations (PROS) had allowed millions of dollars in overpayments
                                  and underpayments. To more adequately ensure the appropriateness of
                                  Medicare payments to institutions, HCFA should more effectively use its
                                  internal   controls   and strengthen      other controls.




                                  Page 13                                      GAO/HRD-9WXi   Aging Issues in Fiscal Year 1989
                            Appendix I
                            Nscal Year 1089 GAO Rqorta on Issuee
                            PrimarUy Af’bcthg Older Axuerlcam




7 ng-Term Care for the
E derly: Issues of Need,
A       and Costs (GAO/
                            In 1986, an estimated 6.2 to 6.6 million elderly dependedon others for
                            help with activities of daily living (ADL) or instrumental activities of
                            daily living. About 20 percent of these dependent elderly lived in nurs-
                            ing homes;the majority lived in the community. Nearly all of the elderly
H D-89-4, Nov. 28, 1988)*   in the community received all or someof their care from informal
                            caregivers-family and friends. A 1982 survey noted that despite help
                            from family and friends, about 40 percent of the elderly with one or
                            more ADL dependenciesstill had unmet needsfor help. Individuals with
                            mental/behavioral problems and/or multiple ADL dependencieswho
                            require extra nursing care and for whom payments will be made by
                            Medicaid are likely to wait the longest for help. The majority of public
                            and private expenditures are for nursing home care; in fiscal year 1985,
                            almost $36 billion of the estimated $46 billion spent nationally for long-
                            term care was for the dependent in the community. Out-of-pocket pay-
                            ments by individuals and their families were an estimated $20 billion in
                            1986 and are expected to continue to rise. Any future strategy for han-
                            dling the growing long-term care needsof the elderly will need to bal-
                            ance the potentially conflicting goals of accessand cost containment.


$ong-Term Care Insurance:   Expenditures for long-term care servicesin the United States are
Qtate Regulatory            expected to exceed$46 billion in 1988, principally for nursing home
                            care. Publicly funded health care programs-Medicare for the aged and
Requirements Provide        Medicaid for the poor-pay less than half, with consumerspaying the
Inconsistent Consumer       remainder. Private long-term care insurance offers potential to help
Protection (GAO/HRD-89-     defray these costs;it is intended to addressthese gaps and limitations in
67, Apr; 24, 1989)”         other insurance, Typically, such policies pay a set amount over a speci-
                            fied period for each day a policyholder uses a covered service. But poli-
                            cies vary considerably in terms of coverage,the amounts payable per
                            day, and other conditions affecting policy value and cost. State
                            approachesto regulating long-term care insurance vary greatly. Half the
                            states have adopted specific legislation, although they vary in the
                            degreeto which they meet the National Association of Insurance Com-
                            missioners’ recommendedminimum standards, Many states allow insur-
                            ers to use policy provisions that offer consumersless protection than
                            recommended.While such provisions can result in lower policy premi-
                            ums, they can adversely affect policyholders by (1) decreasingthe likeli-
                            hood that neededservices will be covered and (2) increasing the risk of
                            policy terminations for reasonsother than nonpayment of premiums.




                            Page 14                                GAO/HRD-9066   Aging Issues in Fiscal Year 1989
   .

                                Appendix1
                                FlscaI Year 1989 GAO Iteporta on Issuer
                                Prharily   Affecting Older Amehans




Medi aid: RecoveriesFrom        Through assetrecovery programs, states can recover from the estatesof
Nurs ng Home Residents’         nursing home recipients or their survivors a portion of the expensesthe
                                state incurs in providing nursing home care. Estate recovery programs
Esta es Could Offset            require Medicaid recipients whose primary assetsare their homes to
Prog am Costs (GAO/HRD-         contribute toward the cost of their nursing home care in the sameman-
89-5 , Mar. 7, 1989)            ner required of recipients whose assetsare in the form of stocks, bonds,
    i                           and cash. Unlike the payments made from liquid assets,however, pay-
                                ments from the home’s equity are deferred until the recipient and his or
                                her spouseand dependent children no longer need the home. Estate
                                recovery programs provide a cost-effective way to offset state and fed-
                                eral costs,while promoting more equitable treatment of Medicaid recipi-
                                ents. GAOstudied Medicaid nursing home programs in eight states to
                                determine the potential financial impact of assetrecovery programs on
                                Medicaid and whether they provide a mechanism acceptableto the
                                elderly for sharing the costs of nursing home care.


Medicaid: SomeRecipients In a limited test in Massachusetts,GAOidentified 143 Medicaid nursing
Neglect to Report U.S.   home residents whose individual bond holdings could render them ineli-
                         gible for benefits. Their combined outstanding bond holdings totaled
Savings Bond Holdings    about $15 million. Most of the holdings were not reported on the indi-
(GAo/HRD-89-43, Jan. 18, viduals’ Medicaid applications, even though the form used in Massachu-
198b)                    setts specifically asks recipients to list government bonds/notes.
                                Although the Social Security Act requires state agenciesthat administer
                                certain federal benefit programs to verify income by comparing the
                                income declared by program applicants and beneficiaries with informa-
                                tion obtained from the Internal RevenueService and the Social Security
                                Administration (SSA), it doesnot require verification of U.S. savings
                                bond holdings. The Department of the Treasury maintains such informa-
                                tion on the value of savings bond holdings, but this information is not
                                currently available to the states. To help prevent ineligible individuals
                                from obtaining Medicaid benefits, GAOrecommendsthat (1) procedures
                                for verifying saving bond holdings be included in an Income and Eligibil-
                                ity Verification System and (2) the Secretary of the Treasury, upon
                                request, make such information available to the states,


Medicare: An Assessment         HCFAhas made several refinements in its analytical approach to hospital
of HCFA’s 1988 Hospital         mortality analyses.It has (1) modified the composition of the 17 broad
                                categoriesused to characterize the principal diagnosis of all Medicare
Mortality Andyses (GAO/         patients, (2) reported outcomesof each hospital over several years
P&MD-89-1IBR, Dec. 13,          rather than a single year, and (3) initiated studies to validate its analyti-
1988)*                          cal approach. However, its current analytical approach and associated


                                Page 15                                   GAO/HRD-90-56   Aging Issues in Fiscal Year 1989
                             Appendix   I
                             FlrcalYear19I3BGAoReporteonxl4sueo
                             prlnwlly   Afmtlng   Older Ameri4zan!S




                             validation efforts still have several limitations that diminish its ability
                             to ensure the validity of its analyses.Until HCFAexpands on its current
                             efforts to validate its approach and to examine the effect of data defi-
                             ciencies,it will be difficult to determine the actual proportion of hospi-
                             tals that are correctly identified as having, or not having, quality of care
                             problems.


M dicare Catastrophic        Membersof Congressand the public have expressedconcern about the
A t: Options for Changil23   Medicare Catastrophic CoverageAct of 1988, particularly about the
                             amount of supplemental premium that higher income Medicare benefi-
Fi1 ancing and Benefits      ciaries will pay. In this report, which provides a summary of options
( AO/HRD-89-156,             available to either revise the benefits and financing under the act or
s%,pt. 15,1989)              phase out the program, GAOfinds no “painless way” to reduce benefici-
                             ary funding, Revenuesfrom other sourceswill need to be raised or bene-
                             fits provided under the act will need to be cut. Compounding the
                             problem from a budget standpoint is that the act was designedto build a
                             contingency reserve so that estimated revenuesexceedestimated costs
                             for the catastrophic program in its early years. Therefore, repeal of the
                             program would increase the federal deficit for Gramm-Rudman-Hollings
                             deficit reduction purposes for the next few years.


Medicare: Health             The report provides an overview to three broad topics of concern relat-
Maintenance Organization     ing to current rate-setting methodology. These issuesare the (1) accu-
                             racy of the forecasted adjusted average-per-capitacost (AAPCC) rates; (2)
Rate-Setting Issues (GAO/    appropriateness of tying health maintenance organization (HMO) pay-
HRD-89-46,Jan. 31,           ment levels to county fee-for-service Medicare cost levels; and (3) poten-
1@39>**                      tial of the current capitation payment system to adversely affect
                             Medicare, its beneficiaries, and HMOS.
                             Forecastsof future costs are made using relatively old data for the base
                             period, becausecomplete data on actual Medicare payments are gener-
                             ally not available until 3 years after a given time period. Thus, the data
                             must be inflated to account for price increasesover time and adjusted
                             for factors such as changesin utilization rates and patterns. Questions
                             have been raised about whether the county is the appropriate unit of
                             local rate-setting, and whether there are alternatives to using local fee-
                             for-service Medicare cost as the means of setting HMOpayment rates.
           Y
                             While the capitation payment system creates strong incentives for the
                             efficient use of resourcesand cost containment, AAPCCcapitation in a
                             fee-for-service environment also creates incentives that may hamper the



                             Page 10                                  GAO/IlRD4h%56   Aging Issues in Fiscal Year 1989
                                 APpe-1
                                Fbcel Year19119GAO Reports on Imuee
                                 Prlmadly AffW OlderAmericans




                                achievement of Medicare’s cost containment and quality-of-care goals.
                                GAOwillpresent the results of its analysis in later reports.


         are: Impact of State   Mandatory assignment laws reduced out-of-pocket health care costs for
                                covered beneficiaries in four states that enacted laws requiring physi-
                                cians, under certain circumstances,to accept Medicare’s approved
                                amount as payment in full. The Massachusettslaw eliminated all billing
                                by physicians that exceededthe amounts allowed under Medicare; the
Septi.19,1989)*                 amount of savings in the other three states (Connecticut, Rhode Island,
     I                          and Vermont) was less clear. Indicators developed by GAOsuggestthat
     /                          physicians have not offset reducing bills for covered beneficiaries by
     I
     I                          increasing bills for noncoveredbeneficiaries. The volume and intensity
    I
    I                           of servicesprovided by physicians to Medicare beneficiaries in three
    I                           states did not increase as somepeople had feared. In Massachusetts,the
    I                           volume and intensity of servicesincreased,but the law’s relative impor-
    I                           tance in causing this increase is not clear. Accessto care was not
                                reduced in the four states as a result of the mandatory assignment laws.
   1

Medicare: Incentives            Medicare
                                  . . . saved _. - _about
                                                     .-_ $1.4
                                                          _ ^billion in fiscal year
                                                                                 ._- 1987
                                                                                      . by paying
                                                                                             _ _ benefi-
                                                                                                   .__
Neetied to Assure Private       ciaries’ medical bills only after other responsible insurers had paid, but
                                it is still paying many claims that other insurers should pay. While
Insvrers Pay Before             Medicare has taken steps to improve the information available for iden-
Medicare (GAO/HRD-89-           tifying claims that others should pay, insurers and contractors do not
19, $Vov.29, 1988)              have adequate incentives to comply. Until they do, Medicare secondary
                                payer provisions will not achieve all possible savings.


Me&care: Indirect Medical       Under Medicare’s prospective payment system, teaching hospitals
Edbcation Payments Are          receive extra payments. These payments are to compensatefor higher
                                patient care costs associatedwith providing graduate medical education,
ToQHigh (GAO/HRD-89-            In fiscal year 1986, the additional payments were about $2.1 billion-
33,iJan. 5, 1989)**             $1 billion for direct medical education costs and $1.l billion for the indi-
                                rect cost of medical education. GAO'Sanalysis showed that the add-on
                                payments to teaching hospitals for the indirect cost of medical education
                                are too high, and GAOrecommendsreducing the teaching adjustments
                                factor, which helps determine these payments.

                Y




                                Page    17                            GAO/HRD-99-56   Aging Issues in Fiscal Year 1989
                           Appendix I
                           Fiscal Year 1989 GAO Reports on Issues
                           Primarily Affecting Older Americans




                           Concernshave been raised that the incentive payments made to physi-
                           cians participating in Medicare may be so strong that they represent a
                           potential threat to the quality of care by encouraging inappropriate
                           reductions in service. Incentive features most likely to adversely affect
                           quality are (1) shifting HMOS'risk to physicians, (2) distributing incen-
                           tives basedon individual physician cost performance, (3) paying a per-
                           centageof HMOsavings on patients, and (4) measuring physician cost
                           performance over a short time period. Strong HMOmanagementcontrols
                           are neededto identify and prevent physician behavior that adversely
                           affects quality of care.


M dicare: Program          This report discusseswhy hospicesare not participating in Medicare,
P ovisions and Payments    the reasonablenessof hospice payment rates, and hospice quality
                           requirements. At least one-half of the nonparticipating hospicessampled
Dt scourage Hospice        during GAO'Snational survey said the main concernsthat led them not to
Participation (GAO/HRD-    participate in Medicare were (1) the language required in hospices’certi-
89-111, Sept. 29,1989)*    fication of terminal illness related to the certainty of the physician’s
  ,                        prognosis of death, (2) the requirement that hospicesobtain contracts
 /,
                           with hospitals for inpatient services,(3) limits placed on aggregatepay-
                           ment amounts and inpatient days, and (4) payment rates.


Medicare PROS:Extreme      The Utilization and Quality Control PROSoperating under contract with
                           HCFAand provide nurse and physician review of hospital medical
Variation in               records for discharged Medicare patients. In fiscal year 1987 these con-
Organizational Structure   tracts totaled $166 million. This fact sheet describesfour aspectsof PRO
and Activities (GAO/       operations: (1) organizational characteristics, (2) review activities,
PEMD-89-7FS,Nov. 8,        (3) PROobjectives and interventions, and (4) relationships with other
X988)*                     health and consumer groups in the state where the PROis located.


Medicare: Reasonableness   Under risk contracts, HMOSagreeto provide all Medicare-coveredser-
of Health Maintenance      vices for a fixed monthly amount per beneficiary (capitation payment)
                           and to experience a profit or loss depending on their cost to do so. Medi-
Organization Payments      care law provides a payment safeguard to help ensure the accuracy of
Not Assured (GAO/HRD-      the methods used to calculate capitation rates. This safeguard, the
89-41, Mar. 7, 1989)       adjusted community rate (ACR) process,is intended to prevent HMOSfrom
                           retaining excessiveprofit from Medicare’s payments. HCFA'Sprocessfor
                           reviewing, validating, and approving ACRsubmissionsprovides little
          *                assurancethat the ACRprocessis meeting its payment safeguard objec-
                           tive. GAO'Scasestudies of ACRSsubmitted by 4 HMOSand review of a


                           Page 18                                  GAO/HRD-90-66   Aging Issues In Nscal Year 1989




                                                                                                 ,’
                             Appendix I
                             Fled Year 1989 GAO Reporta on Iesues
                             Prlmdly  A.ffectin.g Older Americans




                             random sample of ACRSsubmitted by 15 other HMOSshowed that the pro-
                             cessis susceptible to HMOmanipulation and error, This is becauseHCFA
                             doesnot always enforce its requirements that an HMO(1) use its own
                             historic cost and utilization data as a basis for calculating its ACR,(2)
                             follow the prescribed computational methods to account for differences
                             between Medicare and commercial members’ volume and cost of ser-
                             vices, and (3) document the calculations.


Me ‘care: Status Report on   The Secretary of HHSis authorized to conduct demonstrations of con-
  4
Meqicare Insured Group       tracting on a prepaid capitation basis with Medicare Insured Groups
                             (MIGS) to provide Medicare benefits to retirees. A MIG must agreeto pro-
Demonstration Projects       vide the full range of Medicare-coveredservicesto its Medicare-eligible
(G4O/HRD-89-64, June 27,     retirees for a per capita rate of payment. The MIG'Sloss or surplus for
198?)**                      servicing these retirees dependson whether its coststo provide the
   !                         Medicare services are more or less than the capitation payment. HCFA
                             has entered into cooperative agreementswith Chrysler Motors Corpora-
                             tion, Southern California Edison Company, and Amalgamated Life
                             Insurance Company to establish the three MIG projects authorized by the
                             Omnibus Budget Reconciliation Act of 1987. In April 1989, HCFAofficials
                             told GAOthat they were not certain when any of these projects would
                             becomeoperational.


Medicare: Statutory          Medicare seeksto ensure that beneficiaries receive hospital care that is
Mohifications Needed for     medically necessaryand meets professionally acceptedstandards. To
                             detect any violations of such standards, Medicare contracts with PROSto
thk Peer Review Program      examine beneficiaries’ inpatient hospital records. If they identify
Mobetary Penalty (GAO/       instances of improper or unnecessarycare that are gross and flagrant or
HR?-89-18, Mar. 30,          numerous, PROSmust report them to HHS'SOffice of the Inspector Gen-
lQqQ)*                       eral (OIG) and provide appropriate recommendations.In the most seri-
                             ous casesMedicare can exclude the provider from the program. If
                             exclusion is not warranted Medicare can impose monetary penalties
                             instead. The dollar penalty, however, is based on the cost to Medicare of
                             the improper or unnecessarycare, and this cost can be very small. In a
                             1987 memorandum, the OIG advised PROSnot to submit caseswith rec-
                             ommendations for monetary penalties unless the penalty would be cost
                             effective. Specifically, the memorandum indicated that PROSshould not
                             recommendsuch penalties unless, among other things, (1) the provider
                             displayed a pattern, rather than one or two instances,of unnecessaryor
                             poor-quality care and (2) the Medicare program improperly reimbursed
                             the provider a significant amount of money. To make the PROmonetary
                             penalty a useful alternative when exclusion is not appropriate, the


                             Page 19                                GAO/HRD-90456   Aging Issues in Fiscal Year 1989
                            Appendix I
                            NscaI Year 1989 GAO Reports on hmes
                            IWmfwUy Affwting  Older Amerlcnru




                            Social Security Act should be amendedby substituting a fixed dollar
                            limit on monetary penalties for the current cost-basedlimit.


U ‘S.Employees Health       The Medicare Catastrophic CoverageAct of 1988 extends catastrophic
Bi nefits: Rebate for       insurance protection to about 33 million elderly and disabled benefi-
                            ciaries, including Medicare-eligible federal retirees. Many of these fed-
D plicate Medicare          era1retirees are also enrolled in the Federal Employees Health Benefits
C verage (GAO/HRD-8IQ-      Program (FEHBP).To finance the cost of the new catastrophic benefits,
5E, Mar. 23,1989)*          additional Medicare premiums were imposed. Becausefederal employees
                            already pay premiums to have many of these medical costs covered
                            under FEHBP,the Office of Personnel Management(OPM) was directed to
                            reduce FEHBPpremiums to prevent federal retirees from paying twice for
                            the samebenefits.


Ihcome Security

ADP Budget: SSA’s Fiscal    SSA’S fiscal year 1990 information systems budget request for $204 mil-
*ear 1990 Information       lion provides $160.5 million to fund ongoing data processingand tele-
                            phone operations and maintenance. The request includes $43.5 million
Technology Systems          to fund capital investment projects directed at enhancing the capabili-
Budget Request (GAO/        ties of its information systems, such as acquiring additional ADP and tel-
IMTEC-89-60, June 28,       ephone equipment, new software development, and related contractor
1989)”                      services.


ADP Planning: SSA’s         This report presents the results of a review of SSA’SADP report, which
February 1989 Report on     showed the context in which the agency’sfiscal year 1990 information
                            technology budget supports the larger mission of ss~and prepares the
Computer Modernization Is   agency to meet its service demandsthrough the year 2000. The report,
Incomplete (GAO/IMTEC-      however, doesnot identify the specific long-term ADP activities to be
89-76, Sept. 25, 1989)      undertaken; the objectives of each activity; the personnel, equipment,
                            and financial resourcesneededto accomplish them; or their milestones.
                            SSAofficials estimated that it could take the agency until September
                            1990 to develop such detailed information on its computer moderniza-
                            tion activities.




                            Page 20                               GAO/HRD96-56   Aging Issues in Fiscal Year 1989
     i.
     I
     /

                             Appendix 1
                             Fiscal Year 1989 OAO Beports on Imuee
                             PrharIly   Affecting Older Americans




                             In 1982, SSAbegan the field office modernization project to provide for
                             more rapid client service. The project called for increasing the number
                             of computer terminals available to provide automated capabilities for
                             entering information and making benefits calculations on new accounts,
                             thereby eliminating the paper-oriented manual process.GAO found that:
                             (1) SSAmet its initial field office hardware installation schedule by
                             installing 22,892 computer terminals and the new communications net-
                             work in some 1,300 field offices and (2) .%Ahad redesignedportions of
                             its retirement software and planned to complete this redesign by 1992.
                             Also, SSAfield office personnel believed the increasedquantity of termi-
                             nals and the ability to quickly accessdata baseinformation for retire-
                             ment and supplemental income accounts allow personnel to promptly
                             answer client inquiries while clients are in a field office or on the phone.


Agd Discrimination: Use of   GAO reviewed Fortune 100 companies’use of waivers to releaseemploy-

Waivers by Large             ers from certain legal claims under the Age Discrimination in Employ-
                             ment Act of 1967 in special short-term exit incentive programs. These
Cotipanies Offering Exit     programs were designedto encourageemployees’early departure
Incbntives to Employees      through someform of financial incentive. About 80 percent of Fortune
(GAO/HRD-89-87, Apr. 18,     100 companiessponsoredan exit incentive program at least once during
19gs)*                       1979-88.About 30 percent of these companiesrequired their employees
                             to sign a waiver as a condition for receiving enhancedbenefits. Overall,
                             the use of waivers increased during the years 1985-88 and was highest
                             in 1987 and 1988. During those peak years, 35 percent of the companies
                             with exit incentives used them. Officials from companiesthat required
                             waivers said such a practice protected the company from lawsuits. Com-
                             panies not using waivers contended that they were unnecessarybecause
                             of the voluntary nature of exit incentive programs and the adverse
                             effect that waivers would have on employee relations.


Computer Operations:         SSAhas estimated that since 1982, it has spent about $643 million for its
Iniprovements Needed in      computer systems and planned to spend about $170 million in fiscal
                             year 1989 to maintain and further modernize its systems. SSA has not
SoFial Security’s Capacity   effectively performed capacity management activities neededto accu-
Management Program           rately assessits computer capacity needs.For instance, while the
(GAO/IMTEC-89-8,             agency prepares various reports on total system utilization, these
Jan. 18, 1989)               reports do not have sufficient detail at the transaction level; therefore,
                             SSAcannot determine whether the current computer processingenviron-
             I)
                             ment is operating effectively and efficiently. The agency has initiated
                             improvements, but until they are completed, SSA cannot determine its



                             Page 21                                 GAO/HRIMO-56   Aging Issues in Fiscal Year 1989
                                Appendix I
                                FlscaI Year 1999 GAO Reporta on Emm
                                PrharIly   Afl’ectlng Older Americam




                                ongoing capacity requirements and provide assurancethat future com-
                                puter acquisitions are justified.


Di. trict’s Workforce:          The District of Columbia Retirement Reform Act provides for annual
A nual Report Required          federal payments to the District of Columbia’s Police Officers and Fire
                                Fighters’ Retirement Fund. Thesepayments, however, are to be reduced
byi4 the District of Columbia   when the disability retirement rate exceedsan established limit. An
Reitirement ReformMar.
(G+O/GGD-89-57,
                      Act
                          22,
                                enrolled actuary determined the disability retirement rate to be 0.733
                                percent. Sincethis rate is lessthan the established limit of 0.8 percent,
19js9>**                        no reduction is required in the fiscal year 1990 payment to the fund.


Employee Benefits:              Company group health plans, generally financed at least in part by the
Cqmpany Actions to Limit        companies,play a major role in giving retirees and their dependents
                                accessto lifesaving services.However, significant and increasing costs,
Retiree Health Costs            and the potential adverse effects on businessoperations from disclosing
(GAO/HRD-89-31BR,               unfunded benefits, could prompt companiesto take action to change
Feb. 1,1989)                    their health plan provisions. GAOlooked at the retiree health plans of 29
                                medium and large companiesin the Chicago area and found the follow-
                                ing. All 29 companieshave the right to modify or terminate health bene-
                                fits for active workers and retirees due to specific language in the plans.
                                During the 4-year period 1984-88,all the companieschangedtheir plans
                                by adding cost-containment measuresto help ensure that the health ser-
                                vices provided are medically necessaryand qualify for coverageor by
                                raising the amount plan participants pay for health coverageand for
                                medical services received.


Employee Benefits:              Companieshave been financing retiree health care for years. Although
Companies’ Retiree Health       seenas a low-cost employee benefit decadesago, such care now has
                                becomea major concern for employers becauseof demographic and eco-
Liabilities Large, Advance      nomic trends. Retiree health costs have skyrocketed, in part because
Funding Costly (GAO/            there are more retirees than ever before-workers retire earlier and live
BRD-89-51, June 14,             longer. The growing cost has raised questions about the security of
1989)*                          retiree health benefits and companies’ ability to pay future costs. In con-
                                trast to pension plans, where moneys are set aside to pay future bene-
                                fits, companiesgenerally handle costs for retiree health benefits on a
                                pay-as-you-gobasis out of current revenue. By and large, companiesdo
            Y
                                not prefund retiree health care costs. The Congressmay wish to protect
                                retirees’ health care coverageby requiring employers to advance-fund
                                such benefits or provide coveragethat retirees can buy at group rates.



                                Page 22                                GAO/HRJSSO-50   Aging Issues in Fiscal Year 1989
              /
          /*
  .
                                 Appendix I
                                 Flncal Year 1989 GAO Repot      on Imwa
                                 Rimarlly   Af’?ecting Older Americana




Fed&al Employees: Early          This fact sheet examined certain aspectsof the Department of Defense’s
Retikments at the Defense        (DOD'S)managementof the voluntary early retirement program autho-
                                 rized in fiscal year 1988 at the Army Material Command,the Army Avi-
Depgrtment in Fiscal Year        ation Systems Command,the Army Troop Support Command,and the
1989 (GAO/GGD-89-53FS,           Air Force Air Logistics Center. The fact sheet focused on the cost and
Feb.1
    I
      23, 1989)*                 possible adverse affects of large numbers of DODemployeeselecting
          1                      early retirement.


Fed ral Retirement: Use of The use of contractors and other agenciesby OPM,SSA,and the Federal
Con ractors to Implement   Retirement Thrift Investment Board to implement the Federal Employ-
                           eesRetirement System (FERS)was appropriate. OPMpaid about $3.8 mil-
the ederal Employees       lion primarily to develop and print information to help federal
   s
Ret’rement System (GAO/ employeesbetter understand and compare the features of the new sys-
GG$ -89-29, Feb. 1,1989)* tem and the Civil Service Retirement System. SSAcontracted through the
                                Government Printing Office for an automated system, using machine-
      I                         readable forms to respond to federal employees’ requests for social
                                security earnings and coverageinformation at a total cost of $621,506.
      !                         The Thrift Board paid about $14.6 million primarily to develop and
                                operate an automated recordkeeping system and to prepare, print, and
                                distribute materials and forms.


Federal Workforce:              Concernwas raised that agenciesmay be inappropriately classifying
Positions Eligible for Law      jobs as law enforcement positions to help employee recruitment and
                                retention, since federal employeesin the law enforcement officer retire-
Enforcement Officer             ment program receive more generousbenefits that are more costly to
Retirement Benefits (GAO/       provide than the retirement program for other employees.Various laws
GGD-89-24,Feb. 2, 1989)         enacted since 1947 allow employeesin such positions to retire earlier
                                and to receive higher annuities for the samelength of service to main-
                                tain a young and vigorous law enforcement work force. The most recent
                                data available showed that 44,646 employeeswere covered by the spe-
                                cial retirement benefits as of June 30, 1987. From January 1985 through
                                June 1987, the Department of Justice’s law enforcement work force
                                increased by 5,680, and the Department of the Treasury’s U.S. Customs
                                Service law enforcement work force increasedby 817. The majority of
                                the new hires were placed in previously approved positions; thus, the
                                new positions generally did not appear to contribute to the work force
                                increase or to aid in recruitment and retention.
                  Y




                                Page 23                                    GAO/HRDSO-56   Aging Issues in F’iscal Year 1989
        ,

                                  Appendix I
                                  Fiscal Year 1881) GAO Reports on Issuee
                                  Prharlly   Mfectlng Older Amerlcena




     Le+ isragedBuy-Out Funds:    GAO’S  review of the extent to which eight selectedpension plan sponsors
     In estments by Selected      participated in limited partnerships, or leveraged buyout (LBO) funds,
                                  which pool capital for buy-outs, showed that they have invested a rela-
     PeIlt jion Plans (GAO/HRD-   tively small portion of their assetsin LB0 funds. Most sponsorshave
     89i 121, Aug. 1, 1989)*      received higher returns than achieved on other plan investments. Fur-
                                  ther, the sponsorsappear to be selective in choosingthe funds to invest
                                  in, and most had diversified their investments among different funds.


     iG jion Plans: Labor and     The Employee Retirement Income Security Act of 1974 was enacted to
     IR1 Enforcement of the       eliminate mismanagementand abusesof private pension plan assetsand
II                                to ensure that participants of these plans receive the benefits to which
     En bloyeeRetirement          they are entitled. The Department of Labor and the Internal Revenue
     Inc me Security Act          Service are responsible for enforcing the act’s provisions. Labor’s
     (G O/HRD-89-32, Jan. 23,     enforcement activities included: (1) an increasein the number of indi-
     19 a>*                       vidual pension plan investigations closed from 1,269 in fiscal year 1986
                                  to 1,323 in fiscal year 1987 and (2) an increase from about $42 million in
                                  fiscal year 1986 to about $106 million in fiscal year 1987 in the value of
                                  plan assetsrestored and transactions reversed as a result of its actions
                                  against plans with fiduciary violations. The Internal RevenueService’s
                                  efforts included increasing (1) the amount of excise taxes and penalties
                                  assessedfrom $7.9 million in fiscal year 1985 to $12.6 million in fiscal
                                  year 1987 and (2) the proportion of plans examined that were cited for
                                  violations from 20.6 percent in fiscal year 1985 to 32 percent in fiscal
                                  year 1987.


     Poor Performers: How         This report provides insight into how the SSAidentifies and deals with
     They Are Identified and      poor performers. SSA’S performance managementsystem provides super-
                                  visors with a mechanism for dealing with poor performers. Generally,
     Dealt With in the Social     the system produced positive results in caseswhere poor performance
     Security Administration      was identified. Although S&I experienced somesuccess,GAOalso learned
     (QAO/GGD-89-28, Jan. 27,     that poor performers were not always identified and that the process
     1989)                        for dealing with poor performers was not always used. Moreover, some
                                  supervisors said they would be reluctant to initiate performance actions
                                  against unsatisfactory performers in the future.




                                  Page 24                                   GAO/HRDBO-56   Aging Issues in Fiscal Year 1888




                                                            ,”
 .
                             Appendix I
                             Fiscal Year 1888 GAOReports on Ireuea
                             Rlmarlly   AtYectlng Older Americana




         Pensions: Plan      Employer-sponsoredpension plans that qualify for preferential tax
     isions Differ Between   treatment must meet several federal rules designedto improve the
                             equity and security of pension benefits. The Joint Committee on Taxa-
                             tion has estimated that tax preferences for these plans will result in a
                             $46 billion loss in tax revenue in 1989. The report focuseson the most
                             prevalent types of pension plans in industries having most employer-
                             sponsoredplans. It describessomeof the options that large and small
                             companiessponsoring these plans chosein designing their pension plans
                             to meet federal rules. GAO focuseson four provisions: (1) how long work-
                             ers must wait to participate in the plans, (2) how long workers must
                             wait to gain a legal right to receive earned benefits, or “vest,” (3) how
                             plans coordinate or “integrate”’ benefits with social security, and
                             (4) how long workers must wait to be eligible for full retirement bene-
                             fits. The report also discussesthe impact of someof the changesman-
                             dated by the Tax Reform Act of 1986.


Private Pensions:            This briefing report answers questions about pension portability and
Pofiability and              preservation. Portability refers to the ability to transfer years of service
                             credits or pension benefits from one employer to another. Preservation
Prkservation of Vested       refers to encouraging workers to save cashed-outpension benefits for
Pehsion Benefits (GAO/       retirement income.
HRD-89-15BR,Feb. 3,
1989)*

Railroad Retirement:         Rail employment has steadily declined, from 1,680,OOO    in 1945 to
Future Rail Employment       307,000 at the end of 1988. A number of forces are at work that likely
                             will causethis decline to continue to 200,000 or less. The overall drop in
and Trust Fund Solvency      rail employment since 1945 has been influenced somewhat by this coun-
(GAO/HRD-89-30, Apr. 5,      try’s evolution toward a more service-oriented economy. The principal
lti89)                       causeswere the losesof passengerand freight traffic to other means of
                             transportation. Despite lower employment levels in the future, current
                             projections show that the railroad retirement account should be able to
                             pay benefits into the first decadeof the next century. These projections
                             show an improvement in the financial status of the program becauseof
                             a 1988 payroll tax increase,the extension of federal contributions from
                             general revenues, and changesin certain other actuarial assumptions.




                             Page 25                                 GAO/HRD90-56   Aging Issues in Fiscal Year 1989
                               Appendix1
                               Flscd Year1889GAOReqort@
                                                      on Lmea
                               PrlmarUyAf%ct&OlderAmerlcana




Social Security: Leadershi,p   On the basis of its own reviews of the managementexperiencesof dif-
St cture for an                ferent agenciesand studies by others, GAOconcludesthat a single admin-
                               istrator rather than a board would be the best managementstructure for
In ependent Social             SSA.Under a board form of organization, board members are, in princi-
Se urity Administration        ple, able to bring different points of view and different experiencesto
(GT O/HRD-89-164,              the decision-making process.GAO'Swork, however, suggeststhat, in
Se t. 13,1989)*                practice, boards have not proven effective in providing stable leader-
                               ship, insulating decisionsfrom political pressures,and ensuring that
                               diverse viewpoints are consideredin the decision-making process.Con-
                               versely, the single administrator form of organization offers the advan-
                               tage of allowing for clear delineation of authority and responsibility-
                               an operational characteristic found in most successfulpublic
                               enterprises.


So’ ial Security: Results of   Social Security disability claimants whose initial benefit applications are
R&, uired Reviews of           denied may appeal through several layers of administrative and judicial
                               review. The appeal process,however, is very time-consuming. For some
Administrative Law Judge       claimants, even favorable decisionsby administrative law judges (AUS)
Decisions (GAO/HRD-89-         are delayed becausethey are chosenat random for further review by
48BR, June 13,1989)            W’S Appeals Council. This random review processis carried out under
                               the Bellmon Amendment. Early reviews under the amendment were
                               directed at ALJSwho issued favorable decisionsin 70 percent or more of
                               their casesand were so controversial they led to a lawsuit by the Associ-
                               ation of AWS. GAOstudied 5,860 casesreviewed by the Appeals Council
                               in fiscal year 1986. About 91 percent of the decisionsreviewed were
                               approved without objection. Over 80 percent of the casesnot approved
                               initially by the Council eventually becamebenefit awards anyway, In
                               total, only 1.6 percent of the casesreviewed initially were kept off the
                               benefit rolls, Nonetheless,benefit savings resulting from Bellmon
                               reviews appear to be significantly greater than estimated costs.


Sqcial Security: Staff         Morale at SSAhas been identified as a problem in various surveys since
Reductions and Service         1986. SSAemployeesand managers attribute the low morale primarily to
                               staff reductions, which have been underway since fiscal year 1986. In a
Quality (GAO/HRD-89-           1988 GAOsurvey, ss~ field office managers and employeesranked the
106BR, June 16,1989)*          quality of SSA’S service in processingpost-entitlement work loads lower
                               than most of its other services.The agency has assertedthat its quality
            Y                  of service has remained high over the last several years. Its most recent
                               service quality reports submitted to the Congressin March 1989, gener-
                               ally indicates stable performance in the agency,with a major exception
                               being the backlogs and processingtime for hearings before ALJS, which


                               Page 26                             GAO/IiRDBO-66
                                                                               Agiug   Issues in Fiscal Year 1888
  .


                                Appendix I
                                Fiscal Year 1999 GAO Reports on Issues
                                Frhadly    Affecting Older Americans




                                have remained relatively high over the last 2 years. (SeeGAO/
                                HRD-89.37BR.)


       Security: Status and In March 1987, GAOissued a report on the managementof SSA;it con-
                                tained recommendationsto improve program operations and better pre-
                                pare for the future. SSAhas made good progress in beginning to
      agement Improvement       implement these recommendations.The Commissioner and her staff
                                have exhibited much neededleadership in establishing agencywide goals
                                and objectives and developing tracking systems to assure accountability.
                                SSAhas made a number of organizational changes,appointed a senior
                                executive officer, and set up offices for financial managementand stra-
                                tegic planning. It has also made substantive progress in setting up a
                                structured planning processand taken steps to integrate planning with
                                budgeting. The Commissionerhas instituted several major changesto
                                improve the managementof ADP,but SSAneedsto appoint a full-time
                                information resource manager to ensure that efforts are integrated and
                                coordinated and support long-range goals. In someareas, however, addi-
                                tional managementaction is neededto redirect initiatives or to take
                                more effective actions to correct the problems pointed out in the man-
                                agementreport.


Social Security: Time           A median of 7 months is neededfor attorney fees to be approved and
Required to Approve and         paid by %A. The approval and payment processinvolves five steps:
                                (1) notice of disability decision, (2) benefit calculation, (3) fee petition,
Pay Attorney FeesCan Be         (4) fee approval, and (6) fee payment. SSAcan shorten the processby
Reduced(GAO/HRD-89-7,           requiring attorneys to have claimants sign fee petitions before they are
O& 18, 1988)                    sent to the hearing offices, which could save up to 30 days and by per-
                                forming a detailed review of the entire processto determine where other
                                efficiencies may shorten the processtime.


S&al Security: The Trust        The Social Security Amendments of 1977 and 1983 moved the Old-Age,
Fund Reserve                    Survivors’ and Disability Insurance trust funds away from their tradi-
                                tional, pay-as-you-gofinancing basis toward the accumulation of a sub-
Accumulation, the               stantial, though temporary, reserve. Revenues(mainly payroll taxes)
Economy, and the Federal        were set higher than neededto cover current expenditures (mainly
Budget (GAO/HRD-89-44,          retirement benefits), causing the trust fund balance to grow. As annual
Jan. 19,198$*                   trust fund surpluses accumulate, they are invested in special issue US.
                                Treasury securities. That is, the cash receipts that are not currently
                                neededto pay benefits are loaned to the Treasury, which usesthat cash
                                to meet its current requirements.


                                Page 27                                  GAO/HRD-90-66   Aging Issues in Fiscal Year 1989




       ‘3
                            Appendix I
                            Fiecal Year 1989 GAO Re~rta on Iseuea
                            Primarily Affecting Older Americana




                            In 1986, legislation was enacted that removed social security from the
                            unified budget. Now budget documents routinely report separate totals
                            for the on-budget programs and the off-budget social security program.
                            At the sametime, however, the budget documents routinely combine the
                            on-budget and off-budget financial results and projections into a single
                            series of numbers, labeled the “total deficit.” In fiscal year 1988 the
                            social security trust funds had a surplus of $39 billion, The rest of the
                            government ran a deficit of $194 billion, and together with the social
                            security surplus, this produced a combined deficit of $166 billion.
                            The budgetary reality is that the payroll taxes are being used to finance
                            the current operations of the government and are masking the size of
                            the on-budget deficit. The economicreality is that the trust fund
                            reservesconsisting of Treasury securities that are financing current con-
                            sumption rather than productive investment are illusory. They will
                            remain so until the rest of the government achievesapproximate bal-
                            ance between revenues and outlays.


Soc$alSecurity: Views of    GAO was asked to obtain the views of SSApersonnel on the quality of the
Ag&ncy Personnel on         agency’sservice to the public and the impact of staff reductions. Ques-
                            tionnaires were mailed to a sample of 467 managers and 643 employees
Service Quality and Staff   in SSA’Sdistrict, branch, and hearing offices in June 1988. Both employ-
Reductions (GAO/HRD-89-     eesand managers said that quality of service to the public has gone
37BR, Feb. 10,1989)*        down and that morale had gone down due to staff reductions. (See
                            GAO/HRD-89-106.)


Software Maintenance:       One important measure of a computer program’s quality is how well it is
SSA’s Use of Its Software   structured. A well structured program is clearly organized; its logic is
                            apparent and easily understood by a programmer. In contrast, a poorly
Maintenance Package         structured program is not well organized; its logic is complex, making it
(GAO/IMTEC-89-38,           difficult to understand, and increasing maintenance time and cost.
Jurje 15,1989)              Between June 1987 and September 1988, SSAperiodically evaluated the
                            quality of the batch programs supporting its retirement system using a
                            measurement package.GAOanalyzed the package’sevaluation of these
                            programs and found that 1,992 of the 2,441 retirement systems pro-
                            grams evaluated appeared to be poorly structured. SSAhad not taken
                            full advantage of the benefits of the measurement package becauseit
                            had not (1) developed a complete inventory of its programs, (2) ensured
             P
                            that programs are consistently named, or (3) issued specific written
                            guidance to managerson using the package.



                            Page 28                                 GAO/HRD-90-56   Aghg   Issues in Fiscal Year 1989
                             AppendixI
                             Fbcal  Year 1999 GAOReportaon Isaue~
                             I3harily Affecting OlderAmerkam




Vet&ins

Fina cial Audit: Veterans    This report presents the results of GAO’Saudit of the consolidated finan-
Ad inistration’s Financial   cial statements of the Veterans Administration (which became,in March
                             1989, the Department of Veterans Affairs (VA)) for the fiscal years
Stat ments for Fiscal        ended September30, 1988 and 1987. In addition, it addressesthe finan-
Yea s 1988 and 1987          cial condition of VA'Slife insurance and housing credit assistancepro-
(GAII /AFMD-89-69,           grams, which are designedto be financed primarily from self-generated
Sept/.15,1989)               revenues.The report contains separate reports on VA’Ssystem of inter-
    1                        nal accounting controls and on its compliance with laws and regulations.

    ,~ -~~
Fin&tcial Management:        VA has demonstrated a commitment to     strengthen financial management
Opphtunities for             and was one of the first federal agenciesto prepare consolidated finan-
                             cial statements in accordancewith generally acceptedaccounting princi-
Impkoving VA’s Internal      ples for the federal government. However, GAO’Saudit disclosed
Acchnting Controls and       weaknessesin internal controls, which VA has subsequently initiated
Probedures (GAO/AFMD-        actions to correct. The principal weaknessesGAOfound were: (1) a lack
89-Q5,Aug. 11, 1989)         of financial reporting systems that automated the financial system con-
                             solidation processand financial statements; (2) a lack of effective inter-
                             nal controls in the medical care, veterans’ benefits, and housing credit
                             assistanceareas that are intended to ensure proper recoveries of cost
                             and accuracy of account balances;and (3) inadequate automated payroll
                             system controls for ensuring that all VAemployees are paid correctly and
                             on time.


VA iBenefits: Law Allows     In fiscal year 1986, the VApaid about $8.4 billion in compensation bene-
Compensation for             fits to 2.2 million veterans disabled by injuries or diseasesincurred or
                             aggravated during military service. On the basis of a random sample of
DiSabilities Unrelated to    400 veterans receiving compensation,GAOestimated that about 19 per-
Mifitary Service (GAO/       cent of the compensatedveterans had disabilities resulting from dis-
H&D-89-60, July 3 1, 1989)   easesthat were probably neither causednor aggravated by military
                             service, Many of the diseaseswere related to heredity or lifestyle rather
                             than to military service. Basedon the sample, GAOestimates that bene-
                             fits paid for these types of disabling diseasestotaled about $1,7 billion
                             in 1986, Current law doesnot require VA to determine if military service
                             was a contributing factor in the causeof a disease;the Congressmay
             Y
                             wish to reconsider whether these diseasesshould be compensatedas
                             service-connecteddisabilities. Any such changesshould be prospective
                             in order not to affect veterans already receiving compensationbenefits.


                             Page29                                 GAO/HRD90-60
                                                                               AgingIssuesin FiscalYear1989
                            AppendIxI
                            Fiscal Year lB8B GAOBeporta on Issues
                            PrhwiIy    Affeetlng Older AmerIcam




    Health Care:            GAOwas asked to    examine allegations that the VA altered the design of -
   egations Concerning      its patient mortality study to obtain results more favorable to the
                            agency.It was alleged in a newspaper article that VA'S Chief Medical
   ‘s Patient Mortality     Director ordered that the confidence level used in calculating the
   Idy (GAO/HRD-89-80,      number of VA medical centers that had higher-than-expected mortality
                            rates be changed from 96 to 99 percent in order to arrive at a lower
                            number of hospitals with potential quality assuranceproblems. Based
                            on information provided by VA, GAO cannot conclude that the Chief Medi-
                            cal Director or any agency official inappropriately attempted to give the
                            appearancethat it had fewer hospitals with higher-than-expected mor-
                            tality rates than actually exist.


ii Health Care: Delays in   VA was given funding in fiscal year 1988 for 15 major construction
Al ,arding Major            projects, each estimated to cost $2 million or more. Public Law loo-202
                            required that (1) working drawings contracts be awarded by September
C( lstruction Contracts     30,1988, and (2) construction contracts be awarded by September30,
(G 4O/HRD-89-75,Mar. 31,    1989. VA reported that, as of September30,1988, working drawings con-
1s 19)                      tracts for 2 of the 16 fiscal year 1988 projects and construction con-
                            tracts for 3 of the 11 fiscal year 1987 projects had not been awarded as
                            required. Information provided by VA officials indicated that various
                            programmatic considerations causedthe contracting delays. The most
                            common reasonscited for delays were changesin the projects’ scopeor
                            design or receipt of bids that exceededthe available funds.


VA Health Care: Few         Concernwas raised that VA clinics might be denying care to large num-
Veterans Denied Care at     bers of veterans who apply for outpatient medical care in high-demand
                            areas.GAO visited 4 of the 14 VA clinics in Florida, which VA considersto
Florida Clinics (GAO/HRD-   be a high-demand area. GAO estimates the four clinics denied outpatient
89-69, May 3 1, 1989)*      care to less than 1.4 percent of the applicants during fiscal year 1988.
                            These applicants were denied care becauseeither they were not eligible
                            to receive care at VA clinics or the servicesneededwere not available.


VA Health Care:             Verifying physicians’ credentials and examining their ability to perform
Improvements Needed in      specified procedures are important elements of an effective quality
                            assuranceprogram. Despite legislation requiring VA to improve its
Procedures to Assure        credentialing and privileging processes,GAO found after reviewing eight
Physicians Are Qualified    medical centers during 1987-88,that problems still exist. State licenses
(GAO/HRD-89-77, Aug. 22,    were not being consistently verified with state boards; residents’ back-
1989)*                      grounds were not being adequately checked;privileges were not
                            reviewed in a timely manner; credentialing and privileging decisions


                            Page 30                                 GAO/IIRD-90-56   Aging Issues in Fiscal Year 1989




      ,’
          /                                                                                                             I-
 .                                                                                                                      I
          I                    Appendix I
                               Fiscal Yew 1080 GAO Reporta on huea
          I                    Rimwily   Affecting Older Amerkans

          1




                               were not documented;physicians found to be deficient did not have
                               their privileges formally reduced; and the names of physicians found to
                               be incompetent were either not submitted to state licensing boards and/
                               or the Federation of State Medical Boards or not submitted in a timely
                               manner,
      I
     /1
                               Public Law 96-201 requires the Secretary of Veterans Affairs to ensure
                               that VA health care personnel have the basic proficiency in spoken and
                               written English to carry out their responsibilities satisfactorily. VA'S
          iders and Patients   efforts since the law was enacted have significantly reduced the prob-
                               lems with English languageproficiency among its direct health care
                               providers.

VA health Care: Resource       VA'SResourceAllocation    Methodology (RAM)is designedto link medical
Allocation Methodology         centers’ budgets to actual work load and to provide a financial incentive
                               for centers to improve their efficiency. Since 1986, VA has used RAMto
Has Had Little Impact on       transfer funds, through its budget formulation process,from less effi-
Me&Cal Centers’ Budgets        cient medical centers to centersjudged to be more efficient, The RAM-
(GAO/HRD-89-93, Aug. 18,       related adjustments to medical centers’ fiscal year 1989 budgets gener-
1089)                          ally represented less than 2 percent of the total dollars budgeted. The
                               budget adjustments were small in relation to the centers’ budgets
                               becauseVA established a maximum amount that a center’s budget would
                               be increased or reduced in order to cushion the W’S financial impact. In
                               addition, as medical centers incur expensesthat cannot be financed
                               through their existing budgets, the centers’ directors can request further
                               funds from regional directors. The regional directors thus serve as
                               safety nets to help centers cope with financial pressurescausedby RAM-
                               related budget adjustments.


Veterans’ Benefits:            Each year VA pays more than $14 billion for disability benefits and
Improvements Needed in         processesmore than 600,000 initial and reopened applications for these
                               benefits. GAOinvestigated numerous allegations about VA'Sclaims-
Processing Disability          processingpractices and found that the rate of occurrencefor most of
Claims (GAO/HRD-89-24,         the alleged problems was very low or did not appear to adversely affect
June 22,1989)                  benefit decisions.Significant problems, however, were found in these
                               areas: notices to veterans concerning VA decisionson disability claims
                 Y             did not give veterans meaningful information; development of claims
                               was sometimesinadequate; and claims were not always controlled
                               promptly, Overall, these problems resulted in adverse effects on veter-
                               ans in about 13 percent of both the compensation and pension claims.


                               Page 31                               GAO/HRD-90-66   Aging Issues ln Fiscal Year 1989
                              AppendixI
                              FiscalYeul~8~GAORe~rtaonIoi1u~
                              FrimarUy   AfYecting   Older Americans




                              With the exception of notice problems, it was difficult to identify any
                              single causeof these problems.

                              Each year VApays about $14 billion in compensation and pension bene-
  provements Needed to        fits to about 3.8 million veterans and their dependentsor survivors, and
                              about $126 million in burial benefits to veterans’ survivor or estates.VA
                              relies on Statistical Quality Control (sqc) system to determine the extent
                              of errors made in adjudicating claims for these benefits. VA’S SQC system
                              does not provide reliable estimates of the extent of errors made in
                              processingclaims because(1) its casesampling is not consistently ran-
                              dom; (2) regional staff performing SQCreviews are not independent of
                              claims processing;and (3) the central office doesnot ensure that the
                              regions comply with SQCprocedures or that they report errors accu-
                              rately. Moreover, the system does not break out error rate data by pro-
                              gram. As a result, VA lacks the information neededto produce accurate
                              reports or take corrective actions within a given program. VA can
                              improve the reliability of its measurementsof claims adjudication qual-
                              ity by addressingthese problems.


Veterans’ Benefits: Need to   VA cannot ensure that      veterans are given accurate and uniform disability
Update Medical Criteria       ratings becausethe rating schedule has not been adjusted to incorporate
                              the results of many recent medical advances.Without current medical
Used in VA’s Disability       criteria, it is difficult for rating specialists to classify a diseaseor injury
Rating Schedule (GAO/         correctly. As a result, veterans may be assignedinconsistent ratings,
HRD-89-28, Dec. 29, 1988)     and someveterans may be undercompensatedor overcompensated.To
                              better ensure that the rating schedule servesas a practical tool in
                              assigning uniform disability rates, VA should (1) prepare a plan for a
                              comprehensivereview of the rating schedule and, based on the results,
                              revise medical criteria accordingly and (2) implement a procedure for
                              systematically reviewing the rating scheduleto keep it updated.


Other

Aging Issues: Related GAO     This report lists GAOissued products-36 reports, 10 briefing reports,
Reports and Activities in     and 3 fact sheets-concerning activities of the elderly. It also lists 69
                              assignmentsin processas of September30,1988. The reports cover var-
Fiscal Year 1988 (GAO/        ious topics, such as age discrimination and health care.
HRD-89-38,Jan. 26, 1989)*

                              Page 32                                  GAO/HRD-90-66   Aging Issues in Fiscal Year 1989
    i_
    1




Appendix II

F’$cal Year 1989 GAO Reportson Issues
A$fecting
  ,       the Elderly and Others

                            GAOissued 28 reports in fiscal year 1989, on policies and programs in
                            which the elderly were one of several target groups. Of these, 8 were on
                            social and other services,7 on health, 6 on veterans issues,4 on income
                            security, and 4 on housing issues.An asterisk after the report title indi-
                            cates that the review was performed at the request of Committees or
                            Membersof Congress.Two asterisks indicate that the work was man-
                            dated by statute.


He/alth

AD/PPlanning: FDA’s Plans   As part of its mission, the Food and Drug Administration (FDA) is
to timprove Processing of   responsible for assuring consumersthat medical devices and drugs are
                            safe and effective for their intended uses.Responsibility for reviewing
Medical Device and Drug     and approving medical device and drug applications is divided between
Ap’ lications (GAO/         two centers within FDA.The Center for Devicesand Radiological Health,
IM f EC-89-58, June 13,     which reviews medical device applications, has prepared an automated
lQ+Q>
  ,
                            data processingsystem to improve the quality and timeliness of its
                            application reviews. The Center estimates that carrying out its plan will
                            cost $3 million through fiscal year 1993. The Center for Drug Evaluation
                            and Research,which reviews drug applications, has not prepared a plan.
                            The Center is, however, participating in several activities aimed at
                            improving its drug-review process,and Center officials say that they are
                            developing a plan.


ADP Systems: Better         The Health Care Financing Administration (HCFA) and the states depend
Control Over States’        heavily on automated systems to manageand control the annual $48
                            billion in Medicaid program costs.GAOreviewed 129 state requests for
Medicaid Systems Needed     federal funds, submitted between November 1986 and July 1988, to
(GAO/IMTEC-89- 19,          either acquire or enhanceautomated Medicaid systems.GAOfound that
Adg. 2, 1989)*              becauseHCFAhas not issued guidelines concerning the requirement for
                            states to prepare cost-benefit analyses,HCFAapproved 116 of these
                            requests- costing about $119 million-without the means to determine
                            if the projects would be worth their costs or whether the most cost-
                            effective alternative was selected.In addition, GAOnoted that HCFAfunds
                            90 percent of the costs of approved state enhancementsto automated
                            Medicaid systems, rather than 76 percent, as specified in federal
              Y             guidelines.




                            Page33                             GAO/HRD-90-66   Aging Issues in Fiscal Year 1989
                             Appendix II
                             Need Year 1989 GAO lCeport8 on Issuw
                             AffiwtIng the Elderly and Others




 :dalth and Human            This report highlights actions that should be taken in four critical areas
 e’vices Issues (GAO/        affecting the large and diverse operations of the Department of Health
                             and Human Services.The areas include improving departmental man-
   G-89-1OTR,Nov. 1988)      agement,containing the cost of health care, enhancing the financing and
 7                           delivery of social security benefits, and implementing the recently
                             enacted welfare reform legislation.
  I


 iI
ii 1 dicaid: Federal
0 ,ersight of Kansas
F:a$ility for the Retarded
                             One month after it was terminated from the Medicaid program in 1987
                             for deficiencies deemedto pose an “immediate and serious threat” to the
                             health and safety of its residents, the Winfield (Kansas) State Hospital
                             and Training Center for the mentally retarded was reinstated as a Medi-
Ir +dequate (GAO/HRD-89-     caid provider. Staff abuseof residents, resident neglect, inadequate
8151/
      Sept. 29, 1989)        medical and nurse services,inadequate dental services, and poor sanita-
  /,                         tion were the deficiencies cited for termination. Controversy surround-
   I
   I                         ing the reinstatement of the facility, after so short a time, led to a
  ,                          request for GAO to determine whether the regional office complied with
                             Medicaid requirements in its oversight of Winfield. This report contains
                             our analysis of the facility’s termination from the Medicaid program and
                             its subsequentreinstatement.


 :hntal Health: Prevention   In 1980, the Congressamendedthe Public Health Service Act to give
 ?IMentalDisorders and       special attention to efforts, both at the national and at the state and
                             local levels, to prevent mental disability. As of April 1989, however, GAO
Researchon Stress-Related    found that the national prevention goals, priorities, policies, and pro-
Disorders (GAO/HRD-89-       grams required by the 1980 amendment had not been established. The
97, Sept. 12, 1989)*         Deputy Director for Prevention and Special Projects at the National
                             Institute of Mental Health (NIMH) is responsible for carrying out the
                             requirements of the amendment. GAO believes that the Deputy Director
                             lacks the resourcesand authority to accomplish the task. In addition,
                             only one person has served as the Assistant Administrator for Preven-
                             tion at the Alcohol, Drug Abuse, and Mental Health Administration since
                             the position’s creation in 1983; he was appointed in August 1986 and
                             served until June 1987. During fiscal year 1987, NIMH funded 42 grants,
                             totaling over $9 million, that investigated loss-related stress and effec-
                             tive measuresto prevent the development of stress-related disorders.
                             However, the Institute’s stress-related activities were spread among sev-
                             eral divisions with no central direction.




                             Page 34                                GAO/HRD-90456   Aging Issues ln Nscal Year 1989
                            Appendix II
                            Fiscal Year 1989 GAO Repor@ on bsues
                            Affecting  the Elderly and Others




   gcription Drugs:         GAOwas asked to    provide information on the extent to which drug utili-
   lrmation on Selected     zation review systems can identify adverse reactions that may result
                            from (1) the interaction of the prescribed drug with one or several other
   g Utilization Review     drugs, (2) the interaction of the prescribed drug with a known physical
   ;ems(GAO/PEMD-SQ-        condition or illness, (3) the interaction of a prescribed drug with
   May 25,lQSQ)             over-the-counter drugs, (4) incorrect dosages,and (6) the under- and
                            over-utilization of the prescribed drug. The systems reviewed were
                            those at Giant Pharmacies,Long Pharmacies,Thrift Pharmacies,Wal-
                            green Pharmacies,National Data Corporation, Clinical ScreeningPro-
                            gram, Home Shopping Network, and the Tri-Service Mirco Pharmacy
                            System of the Department of Defense.In summary, the information
                            neededto identify adverse reactions through the drug utilization review
                            system and the patient profiles is currently available in at least some
                            operating systems. In addition, issuesconcernedwith data security were
                            dealt with, to somedegree,by all systems.


Pr ‘scription Drugs:        Current research on prescription practices for the elderly clearly indi-
HC A’s Proposed Drug        cates that inappropriate drug prescription can causeadverse drug reac-
   1                        tions, which can lead to drug-induced illness, hospitalization and even
Utilization Review System   death. In addition, inappropriate drug prescription leads to enormously
Igtiores Quality of Care    wasteful expenditures by the government, private insurance companies,
Issires (GAO/PEMD-SQ-       and of course,the recipients of these prescriptions. The Medicaid Cata-
26BR, July 13, 1989)*       strophic CoverageAct of 1988 covers outpatient prescription drug costs
                            for an estimated 17 percent of the elderly and provides a mechanism for
                            checking the safety of drugs for all the elderly who use a participating
                            pharmacy. This mechanism is an electronic drug utilization review sys-
                            tem for prescription at the point of sale. The review system function
                            proposed by HCFAis very basic with regard to drug information to be
                            produced: it will only compare drug-to-drug interactions for a limited
                            number of drugs. Several important issuesremain unresolved. It is also
                            questionable whether HCFA'Ssystem will meet the legislative objectives
                            of being operational by January 1, 1991, and be consistent with the
                            law’s requirements.




                            Page 35                                GAO/HRD90-56   Aging Issues in Fiscal Year 1989
       I
       I
E      I
       1
                                   Appendix II
                                   Fiscal Year 1@13@ GAO Reporta on Issues
                                   Afhcting   the Elderly and Others
I




                                   This report on the Department of Housing and Urban Development
                                   (HUD) describesGAO'Sconcernsabout two important issuesthat need
                                   closer attention-low-income housing and homelessness.If these issues
                                   are not addressed,the Secretary of HUD can expect (1) continuing
                                   decreasesin the supply of rental housing that is available and afforda-
                                   ble to low-income people and (2) a growing national homelessnessprob-
                                   lem. In this report, we offer a wide range of observations and
                                   suggestionson how the Secretary can best addressthese concerns.


    Hobsing Conference:            For many years, the federal government has played an important role in
    Nqkional Housing Policy        ensuring and providing an adequate and affordable supply of decent
                                   safe, and sanitary housing for many citizens. However, since 1980, fed-
    Isskes (GAOIRCED-89-174,       eral funding for housing programs has been reduced substantially for
    Ajg. 1989)                     someprograms, and others have been targeted for further reduction or
                                   even elimination. The Congressand the administration have again begun
                                   to emphasizethe need for immediate attention to programs that would
                                   provide an adequate and affordable supply of housing, including hous-
                                   ing for the homeless.This staff study was sponsoredby GAOto help it
                                   plan its future work on the problems of availability and affordability of
                                   housing for low-income households,homelessindividuals and families,
                                   and first-time buyers. In view of the recently disclosedproblems in mis-
                                   managementat HUD, GAOalso plans to undertake studies of internal con-
                                   trols in various Hun programs.


    PGrtnership Projects:          This fact sheet focuseson federal programs that support public-private
    Ftideral Support for Public-   partnerships in housing and community development. It describesfed-
                                   eral programs currently supporting partnerships and, in particular, four
    Private Housing and            characteristics of those programs: (1) purpose, (2) types of assistance,
    Dqvelopment Efforts            (3) mediating agents, and (4) target populations.
    (GAO/PEMD-89-25FS,
    Sept. 14,1989)


                 Y




                                   Page 36                                   GAO/HRD-90-66   Aging Issues in Fiscal Year 1989
                                    F&W Year 1989 OAO Reports on Issues
                                    Af%cthg the Elderly and Others




  Tax                       The 19 publicly offered partnerships being marketed for low income
  Ass                       housing tax credit projects on averageuse a higher proportion of equity
                            to pay fees and expensesthan those for residential and residential/com-
  Incc e Housing Tax Credit mercial investments. The low income housing partnerships devote an
  Par7                      average 27 percent of equity for fees and expenses,while the other
( 89-l                      types of investments use about 21 percent for this purpose. According to
                                    industry analysts, the proportion of fees and expensesspent by these
                                    low income housing partnerships are generally within guidelines issued
                                    by the North American Securities Administrators Association, Inc.


      bme Security

      bloyeeStock            Employee Stock Ownership Plans (ESOPS)are recognizedunder the
      hership Plans:         Employee Retirement Income Security Act as a type of defined contribu-
                             tion plan. Unlike other defined contribution plans, ESOPShave multiple
  All&ation of Assets i      purposes. In addition to providing retirement or deferred income to par-
  Se1‘cted Plans (GAO/;~HRD- ticipants, their objectives include (1) improving productivity by giving
  89-3 1, June 5, 1989)*     workers an owner’s stake in the successof the company, (2) broadening
                                   stock ownership and transferring company ownership to employees,
                                   and (3) providing a way to finance company operations or buy out
                                   existing owners. GAOreviewed nine ESOPSestablished in 1986. The data
                                   obtained on the nine plans showed that their ownership of company
                                   stock ranged from 2.2 to 100 percent; five plans owned less than 15 per-
                                   cent and four owned over 60 percent. Individual participant account
                                   balancesranged from $467 to $38,311. All nine plans allocated assets
                                   basedon participant salaries. In three plans, the participants with the
                                   highest percentageof ESOPassetswere company officers who also held
                                   company stock that was not in the plan.


  Federal Compensation:            State and other governmental entities impose premium taxes on insur-
  Premium Taxes Paid by            ante underwriters that service participating plans in the Federal
                                   Employees Health Benefits Program. In 1987, 22 of the 26 participating
  the’ Health Benefits             fee-for-service plans charged the health benefits program about $44 mil-
  Program (GAO/GGD-89-             lion for premium taxes imposed by the 60 states and other entities,
  102, Aug. 8, 1989)               including the District of Columbia and the Republic of Panama. These
                                   taxes are included in the plans’ premiums charged to enrolles and the
                  Y                federal government. In 1980, the Congressexempted Federal Employees
                                   Group Life Insurance Program premiums from similar premium-based
                                   taxes becauseit consideredthe program to be self-insured and because


                                   Page 37                                GAO/IUD-90-50   Aging Issues in Fiscal Year 1989
                             AppendixII
                             Fiscal Year 1989 GAOReporta on Issuers
                             AffeetJng   the Elderly   and Others




-
                             states generally do not tax self-insured programs. Sincethe health bene-
                             fits program operates in a similar fashion, the Congressmay want to
                             consider exempting the health insurance program from premium taxes
                             as well.


SC
    1
 ) ial Security: Selective   Nearly two-thirds of the people who apply to SSAfor disability benefits
Fr ce-To-FaceInterviews      are initially denied them. The state Disability Determination Service
                             (DDS) makes the initial disability determinations for claimants. Many
W’ th Disability Claimants   appeal this decision, asking for reconsideration; someappeal to an
cc ‘uld ReduceAppeals        administrative law judge (ALJ). ALJS reverse DDSdecisions in over 60 per-
  t O/HRD-89-22, Apr. 20,
(Glp.                        cent of the casesthey decide, often disagreeing with DDSdeterminations
1:$89)*                      about claimants’ remaining ability to work. Someof these appeals might
                             be avoided if DDSinterviewed selectedclaimants at the reconsideration
                             stage. To date, the limited experience with face-to-face interviews at the
                             reconsideration stage suggeststhat these interviews improve decisional
                             quality and resolve somecasesthat would otherwise go to AWS for
                             appeal.

  I
E jcial and Other
SCirvices

  ock Grants: Federal-       Current flexibility of states in collecting data on block grant programs
State Cooperation in         contrasts markedly with data collection requirements under previous
                             programs, which required states to adhere to federal standards. The
Developing National Data     Congress,in an effort to receive uniform data, legislated the develop-
Collection Strategies        ment of model criteria and standardized forms for someblock grants
(GAO/HRD-89-2, Nov. 29,      that rely heavily on voluntary state cooperation. Through this approach
1?88)*                       the data were timely, and officials in the six states GAOreviewed-cali-
                             fornia, Maryland, Pennsylvania, Rhode Island, Texas, and Virginia-
                             perceived the collection efforts to be less burdensome.However, data
                             collected through this approach for block grants were not always com-
                             parable acrossstates. National leadership in developing standard forms
                             and definitions can improve data comparability.


             Y




                             Page 38                                  GAO/HRD-90-66   Aging Issues ln Fiscal Year 1989
                               Appendix II
                               Flucal Year lBS9 GAO aeporta on Imtes
                               Mlrectlng the Elderly andOthers




Co munity Development:         Under the Community Development Block Grant, Small Cities Program,
Dis ribution of Small Cities   funds are allocated to the states on a formula basis for the development
                               of viable communities by providing decent housing and a suitable living
Fun s by Pennsylvania          environment and expending economicopportunities for low- and
(G O/RCED-89-111,              moderate-incomepersons.GAOwas asked to review the methodology
Ma 3,1989)*                    Pennsylvania used to distribute its funds. Someof GAO'Sfindings showed
                               that the state’s methodology for estimating the percentageof low- and
                               moderate-incomepersons is not consistent with the Housing and Com-
  i                            munity Development Act of 1974. The act says that estimates should be
                               developed using income criteria and income data for the sameyear.
                               Pennsylvania’s methodology compared 1979 income levels with 1983
                               income criteria. The result is that the number of communities that are
                               predominately of low and moderate income is higher than if HUD'Sesti-
                               mates were used. The Department believes that the methodology the
                               state usesoverestimates the low- and moderate-incomepopulation in
                               certain areas and has required the state to use HUD’S estimates or some
                               other appropriate alternative to distribute Small Cities funds.


Finhcial Audit: Food and       This report examines the statement of financial position of the Food and
Nutrition Service’s            Nutrition Service, an agency of the Department of Agriculture, as of
                               September30, 1987. This is the first year that the Service’sfinancial
Finkncial Statements for       statements have been subjected to an audit in accordancewith generally
1987 (GAO/AFMD-89-22,          acceptedgovernment auditing standards. In addition, we also report on
Mar. 15, 1989)                 our study and evaluation of the Service’sinternal accounting controls
                               and on its compliance with laws and regulations.


Foqd Stamp Program:            States have adopted a number of procedures to assureeligibility for
Adhinistrative Hindrances      Food Stamp Program benefits and ensure that needy people receive the
                               appropriate amount of assistancein the most economical and efficient
to Farticipation (GAO/         way possible. However, under certain circumstances,procedures
RCED-89-4,Oct. 21, 1988)*      adopted by the states GAOvisited (California, Illinois, Maryland,
                               Oklahoma, and Texas) have prevented or delayed eligible households
                               from applying for food stamps and participating in the program. For
                               example, GAOfound that two offices conducted normal businessonly
                               four days each week, which limited accessto food stamp services;all
                               local offices in one state and one local office in each of two other states
                               did not consider applicants for expedited benefits or provide expedited
                               benefits on time; and three local offices in one state did not always help
                               applicants obtain the documentsthey neededto complete their
                               applications.



                               Page 39                                 GAO/IUD-90-56   Aging Issues in Fiscal Year 1989
                                 Appendlx II
                                 Nucd Yew 1989 GAO Bepartn on Issue
                                 Affecting the Elderly and Others




Fbod Stamp Program:       The Food Stamp Program is designedto provide low-income household
Pbticipants Temporarily   members   additional food-purchasing power to help them acquire an ade-
                          quate low-cost diet. However, eligible program participants can be tem-
Tkrminated for Procedural porarily terminated from the program if they do not comply with
                                 procedural requirements. GAO,on the basis of its sample, estimates that
                                 about 49 percent of the householdsin Georgia and about 68 percent in
                                 Wisconsin experienced breaks in service. Participant-caused breaks
                                 resulting in benefit losseswere causedby participants not (1) submitting
                                 timely monthly reports, (2) providing requested verification documents,
                                 (3) notifying their local office regarding the nonreceipt of stamps, or
                                 (4) meeting work requirements. Other participant-caused breaks were
                                 due to participants not filing timely or complete new applications for
                                 recertification.


Food Stamps: Reasonsfor          In both 1979 and 1986 slightly more than half of the householdseligible
Nonparticipation (GAO/           for food stamps did not participate in the program becausethey did not
                                 think they were eligible. Approximately one-third of the 60 percent who
PEMD-89-5BR,Dec. 8,              did not think they were eligible thought their assetsor income were too
liSSS)*                          high for the program. About two-thirds of the eligible nonparticipants
 /                               who thought they were eligible for benefits did not try to get food
                                 stamps. The reasonsthis group gave most frequently for not participat-
                                 ing in the program were: (1) they did not need the benefits and (2) they
                                 were concernedabout the likely administrative “hassles.”


Montana Indian                  This briefing report contains information applicable to the Blackfeet,
Reservations: Funding of        Flathead, Fort Balknap, and Northern CheyenneIndian Reservationsin
                                Montana. Specifically, it mentions (1) state and county health care and
SelectedServices,               social servicesfor Indians, (2) funding information for school districts
Taxation of Real Property       serving Indian students, and (3) taxes billed by counties for real prop-
(GAO/HRD-89-lBR,                erty located on the reservations and taxes not billed due to the tax-
(i)&. 11, 1988)*                exempt status of trust and tribally owned properties.


Parental Leave: Revised         GAOwas asked to    estimate the cost of adding a provision allowing 10
Cost Estimate Reflecting        weeks of unpaid leave to care for a seriously ill spouseto H.R. 770, the
                                Family and Medical Leave Act of 1989. H.R. 770 permits an employee to
the Impact of Spousal           take up to 10 weeks of unpaid leave over a 2-year period upon the birth
Leave (GAO/HRD-89-68,           or adoption or placement for foster care of a child, or the serious health
Apr. 6, 198S)*                  condition of a child or parent, and up to 15 weeks every year for per-
                                sonal illness. Upon returning to work, the employee is guaranteed the



                                Page 40                               GAO/HRD90&3   Aging Issues in Fiscal Year 1989
                           Appendix II
                           Flucal Year 1989 GAOReporta on Issues
                           Affecting the Elderly and Others




                           same or equivalent job. The legislation requires employers to continue
                           health benefits for workers while on unpaid leave on the samebasis as
                           if they were still working, but doesnot require the continuation of other
                           employee benefits. The proposed provision would provide the samejob
                           protection and health benefits for spousal leave.
                           The estimated cost of H.R. 770 to employers having 60 or more workers
                           would be about $188 million annually. If the legislation is expanded to
                           include leave to care for a seriously ill spouse,the cost increasesby $142
                           million to about $330 million annually. When firms employing between
                           36 and 49 people are included, the cost of H.R. 770 is estimated to be
                           $212 million annually, which increasesto $368 million annually when
                           the provision to care for seriously ill spousesis included.


    mns

Defdnse Health Care:       Overall, patients expressedsatisfaction with the care they received in
Patients’ Views on Care    all nine military treatment facilities GAOsurveyed. High percentagesof
                           patients said they would want to go again to the samefacility, for both
Thei Received (GAO/HRD-    inpatient and outpatient care. Despite generally favorable ratings, 53
89-437, Sept. 13, 1989)    percent of the outpatients and 39 percent of the inpatients commented
                           negatively on someelement of the care they received. Each facility sur-
                           veyed had established patient representative programs to handle com-
                           plaints and conduct surveys.


Defense Health Care:       The first priority of military hospitals is to treat active duty members,
Workload Reductions at     When space,staff, and other resourcesare available, however, they also
                           care for military retirees and dependents.For outpatient care, these
Military Hospitals Have    beneficiaries can choosebetween military facilities and civilian hospitals
Increased CHAMPUS Costs    and physicians under Civilian Health and Medical Program of the Uni-
(GAO/HRD-89-47, July 10,   formed Services(CHAMPUS).The amount and cost of care provided under
198p)**                    CHAMPUShave increased in part becausethe amount of care provided to
                           beneficiaries at military facilities has declined. Other reasonsfor
                           CHAMPUScost increasesinclude increases(1) overall in the cost of pro-
                           viding medical care, (2) in the number of military beneficiaries, and (3)
                           in the rate at which they utilize the medical care system. DoD has initi-
            Y              ated several actions designedto increasethe availability of services at
                           military facilities and reduce CHAMPUScosts. These initiatives, however,
                           have not been in operation long enough to determine their impact,


                           Page 41                                 GAO/HRJMO-56   Aging Issues in Fiscal Year 1989
                               Appendix II
                               Fled Year 1989 GAO Report@ on Ieeuee
                               Affectlug the Elderly and Others




&D Health Care: Issues I       Various private sector nursing organizations had expressedconcern that
IdVolVing   Military   ~~~~~   military nurse specialists-nurse anesthetists, nurse midwives, and
                               nurse practitioners-are not being granted the administrative and
Sbecialists (GAO/HRD-89-       clinical responsibilities that their training justifies. Nurse specialists are
2p, Mar. 29, 1989)*            individually privileged or authorized to perform specific functions (e.g.,
                               initiate, alter, or terminate medical care regimens) within established
                               medical protocols and service guidelines. As matter of practice, how-
                               ever, DODphysicians are ultimately responsible for the care provided to
                               patients in military treatment facilities. For this reason, a health care
                               provider who is not a physician may not practice totally independent of
                               a physician. Other issuesraised involved military nurse specialists’ pro-
                               motions and their input to DODpolicy. According to DODofficials, nurse
                               specialists who are promoted to the rank of lieutenant colonel (Army
                               and Air Force) or commander (Navy) and higher ranks may be required
                               to assumesupervisory or managementresponsibilities. In most
                               instances,however, they will also continue to do clinical work within
                               their specialties. Concerning input to policy, according to most specialty
                               advisers, their input is solicited and used by the services but less so in
                               DOD.

I


l$OD Health Care:              Occurrencescreening is one of several elements in the DOD'Shospital
Occurrence Screen              quality assuranceprogram. It involves a review of patient records by
                               trained personnel who use designated criteria to identify occurrences
Program Undergoing             that represent deviations from normal procedures or expected out-
Changes,but Weaknesses         comes.Examples include a patient who had a drug or transfusion reac-
Still Exist (GAO/HRD-89-       tion or was unexpectedly returned to an operating room after initial
36, Jan. 5, 1989)*             surgery. Substantial numbers of occurrenceswere not being identified
                               during the initial screeningprocess.DOD'Srecent policy changeswere
                               designedto improve the utility of the program at the hospital level and
                               were neededto achieve greater acceptanceof the program by the hospi-
                               tals. The extent to which these changeshelp to improve individual hos-
                               pitals’ programs will depend on how the hospitals and services design
                               and implement their programs within the revised policy framework.




                               Page 42                                GAO/HRDM-56Aging   Issues in Fiscal Year   1989
    -
                                  Appendix II
I                                 Fiscal Year 1989 GAO Reports on Issues
                                  Affecting  the Elderly and Others




    ii 1 Health Care: Extent      Concern was raised that military physicians were spending time per-
    to WhichMilitary              forming office managementtasks, such as answering phones and typing
                                  documents,that would be better spent providing medical care. There is
    PI   rsicians Perform         general agreementwithin DODand the military servicesthat physicians
    Al   ninistrative Tasks       are performing clerical and administrative tasks and that this detracts
    (G   ,O/HRD-89-53, Feb. 13,   from their clinical practice time and adversely affects their productiv-
    1E   g>*                      ity. Although the full extent of the administrative support problem and
                                  its effects are unknown, DODhealth care professionals agree that it is a
                                  serious matter requiring priority attention. Each service has initiated or
                                  planned various actions to addressthis issue,but the impact of these
                                  actions may not be felt for a long time.




                                  Page 43                                  GAO/HRD-90-66   Agiug Issues in Fiscal Year 1989
Appendix III

F’iscalYear 1989 GAO Testimony Relating to ’ i
Qsues  Affecting the Elderly                 \:2
 I                                           1I
                                              i
               GAOtestified 26 times before congressionalcommittees during fiscal year
               1989 on issuesrelating to older Americans. We testified 11 times on
               income security issues, 10 times on health issues,twice on social service
               issues,twice on veterans’ issues,and once on housing issuesrelated to
               the elderly.

J              Federal Employees Health Benefits Program, by Bernard L. Ungar, Gen-
k.ealth        eral Government Division, before the Subcommittee on Compensation
               and Employee Benefits, HouseCommittee on Post Office and Civil Ser-
               vice (GAO/T-GGD-89-26,May 24, 1989).
               Insufficient AssurancesThat Board and Care Residents’ NeedsAre
               Being Identified and Met, by Janet L. Shikles, Human ResourcesDivi-
               sion, before the SenateSpecial Committee on Aging (GAO/T-HRD-89-9,
               Mar. 9, 1989).

               Medicare: Cutting Payment SafeguardsWill Increase Program Costs,by
               Michael Zimmerman, Human ResourcesDivision, before the Subcommit-
               tee on Labor, Health and Human Services,and Education, SenateCom-
               mittee on Appropriations (GAO/T-HRD-89-6,Feb. 28, 1989).

               Medicare: GAOViews On the Payment System For Outpatient Cataract
               Surgery, by Michael Zimmerman, Human ResourcesDivision, before the
               Subcommittee on Health, House Committee on Ways and Means(GAO/T-
               ~~~-89-16,Apr. 10, 1989).

               Medicare: Indirect Medical Education Payments Too High, by Michael
               Zimmerman, Human ResourcesDivision, before the Subcommittee on
               Health, House Committee on Ways and Means(GAO/T-HRD-89-14,Apr. 11,
               1989).
               Medicare: Physician Incentive Payments by Prepaid Health Plans Could
               Lower Quality of Care, by Sarah F. Jaggar, Human ResourcesDivision,
               before the Subcommittee on Health, HouseCommittee on Ways and
               Means(GAO/T-HRD-89-19,Apr. 25, 1989).
               Medicare: Referring Physicians’ Ownership of Laboratories and Imaging
               Centers, by Michael Zimmerman, Human ResourcesDivision, before the
               Subcommittee on Health, HouseCommittee on Ways and Means(GAO/T-
               HRD-89-24,June 1, 1989).




               Page 44                            GAO/HRD-90-66   Aging Issues in Fiscal Year 1989




                                                     .
                   Appendix IIl
                   Fbcd Year 1989 GAO Testimony   Relating   to
                   beuea At’fbcting the Elderly




  I


                   Medicare: Referring Physicians’ Ownership of Laboratories and Imaging
                   Centers, by Michael Zimmerman, Human ResourcesDivision, before the
                   Subcommitteeon Health and Environment, HouseCommittee on Energy
                   and Commerce(GAO/T-HRD-89-26,June 8, 1989).

                   Medigap: Insurance Effects of the Catastrophic CoverageAct of 1988 on
                   Future Benefits, by Michael Zimmerman, Human ResourcesDivision,
                   before the SenateCommittee on Finance (GAO/T-HRD-89-22,June 1, 1989).
                   Medigap Insurance. Effects of the Catastrophic CoverageAct of 1988 on
                   Benefits and Premiums, by Michael Zimmerman, Human ResourcesDivi-
                   sion, before the Subcommittee on Commerce,Consumer Protection, and
                   Competitiveness,HouseCommittee on Energy and Commerce(GAO/T-
                   Han-89-13,Apr. 6, 1989).

                   GAOAudits   of Accounting and Financial ManagementSystems at the
Hcusing            Federal Housing Administration, by Charles A. Bowsher, Comptroller
                   General of the United States, before the Subcommittee on Housing and
                   Urban Affairs, SenateCommittee on Banking, Housing and Urban
                   Affairs (GAO/T-AFMD-89-13,Aug. 2, 1989).

                   Age Discrimination: Use of ADEA Waivers by Large Corporations, by
In come Security   Joseph F. Delfico, Human ResourcesDivision, before the Subcommittee
                   on Labor, SenateCommittee on Labor and Human Resources(GAO/T-
                   HRD-89-11,Mar. 16, 1989).

                   Employee Benefits: Companies’Retiree Health Liabilities Large, Even
                   With Medicare Catastrophic Insurance Savings,by Lawrence H. Thomp-
                   son, Human ResourcesDivision, before the Subcommittee on Oversight,
                   HouseCommittee on Ways and Means(GAO/T-HRD-89-29,June 14, 1989).
                   Federal Employees Health Benefits Program, by Bernard L. Ungar, Gen-
                   eral Government Division, before the Subcommittee on Compensation
                   and Employee Benefits, HouseCommittee on Post Office and Civil Ser-
                   vice (GAO/T-GGD-89-26,May 24, 1989).
                   GAO'SViews on H.R. 791, A  Bill to Establish the Social Security Adminis-
                   tration As an Independent Agency, by Joseph F. Delfico, Human
           Y       ResourcesDivision, before the Subcommitteeon Social Security, House
                   Committee on Ways and Means(GAO/T-HRD-89-7,Mar. 1, 1989).



                   Page 45                                        GAO/HRD90-66   Aging Issues in Fiscal Year 1989
                    Appendix m
                    Fkal Year 1080 GAO Testimony    Relating   to
                    Issues Aff’ecting the Elderly




                    GAO'SViews on an Independent Social Security Administration   and the
                    Personal Earnings and Benefit Statement, by Joseph F, Delfico, Human
                    ResourcesDivision, before the Subcommitteeon Social Security and
                    Family Policy, SenateCommittee on Finance (GAO/T-HRD89-23, June 2,
                    1989).
                    H,R. 2614: Federal Retirement Thrift Savings Plan, by Bernard L. Ungar,
                    General Government Division, before the Subcommitteeon Compensa-
                    tion and Employee Benefits, HouseCommittee on Post Office and Civil
                    Service (GAO/T-GGD-89-36,July 26, 1989).

                    Pension Plans and Leveraged Buy-Outs, by Joseph F. Delfico, Human
                    ResourcesDivision, before the Subcommitteeon Oversight, House Com-
                    mittee on Ways and Means(GAO/T-HRD-89-20,Apr. 27, 1989).

                    Pension Plan Participation in Leveraged Buyout Funds, by Joseph F.
                    Delfico, Human ResourcesDivision, before the Subcommittee on Labor-
                    ManagementRelations, HouseCommittee on Education and Labor (GAO/
                    T-HRD-89-6,Feb. 9, 1989).

                    Social Security Administration’s System Modernization Plan, by Michael
                    Zimmerman, Information Managementand Technology Division, before
                    the Subcommittee on Social Security, House Committee on Ways and
                    Means(GAO/T-IMTEC89-11,Sept. 28,1989),
                    Social Security Administration- The First 6 Months of 800 Phone Ser-
                    vice, by Joseph F. Delfico, Human ResourcesDivision, before the Senate
                    Gial Committee on Aging (GAO/T-HRD-m-16,    Apr. 10, 1989).

                    The Social Security Notch Issue, by Joseph F. Delfico, Human Resources
                    Division, before the Subcommittee on Social Security and Family Policy,
                    SenateCommittee on Finance (GAO/T-HRD-89-2,Jan. 23, 1989).


                    GAO'SCost Estimate of the Family and Medical Leave Act of 1989 (H.R.
cl?
   -V
UULlUl   Services   7701. bv William .J. Gainer.
                                         - ---~---I -- lrn&
                                                    HIResourcesDivision, before the Sub-
                    committee on Labor-ManagementRelations, HouseCommittee on Educa-
                    tion and Labor (GAO/T-HRDI89-4,Feb. 7,1989).
                    GAO'SCost Estimate of  the Family and Medical Leave Act Proposal, by
            Y       William J. Gainer, Human ResourcesDivision, before the Subcommittee
                    on Children, Families, Drugs, and Alcoholism, SenateCommittee on
                    Labor and Human Resources(GAO/T-HRD-89-3,Feb. 2, 1989).


                    Page 46                                         GAO/HRD-90-50   Aging Issues in Fiscal Year 1989
          Neal Year 1989 GAO Testimony   Relating   to
          Iames Affecting the Elderly




          Implementation of the CHAMPUSReform Initiative, by David P. Baine,
r;erans   Human ResourcesDivision, before the Subcommitteeon Military Person-
          nel and Compensation,HouseCommittee on Armed Services(GAO/T-
          HRD-89-17,Apr. 18, 1989).

          Implementation of the CHAMPUSReform Initiative, by David P. Baine,
          Human ResourcesDivision, before the Subcommittee on Manpower and
          Personnel,SenateCommittee on Armed Services(GAO/T-HRD-89-26,June
          6, 1989).




          Page 47                                        GAO/HRD-90-66   Aging Issues in Fiscal Year 1989
        ,
:i/~
‘1
‘Ij

         elating to IssuesAffecting the Elderly ’

                        At the end of fiscal year 1989, GAOhad 114 ongoingjobs that were
                        directed primarily at the elderly, or had older Americans as one of sev-
                        eral target groups. Of these, 48 were on health issues,31 on income
                        security issues,20 on veterans’ issues, 11 on social and other services,3
                        on housing issues,and 1 on other issues.One asterisk after the title indi-
                        cates that the activity was requested by Committees or Members of Con-
                        gress.Two asterisks indicate that the work was mandated by statute.
                        Further information on these studies is available from the following:
                        Joseph F. Delfico, 275-6193,Director, Income Security Programs, for
                        income security and veterans issues;Janet Shikles, 2756451, Director,
                        Public and National Health Issuesfor general health issues;David P.
                        Baine, 2758027, Director, Federal Health Care Delivery Issues,for
                        Department of Defenseand veterans’ health studies; Linda Morra, 275
                        1666, Director, Intergovernmental Issuesand Management,for social
                        and other service issues;John Ols, 275-5526,Director, Housing and
                        Community Development Issues,for housing studies; Robin Nazarro,
                        276-3198,Issue Area Coordinator, Information Management and Tech-
                        nology, for ADP studies; Kay Drake, 276-9422,Issue Area Planner,
                        Accounting and Financial ManagementDivision, for financial studies.
                        For studies followed by a “+,” contact Carl E. Wisler, 275-1864,Direc-
                        tor, Planning and Reporting, Program Evaluation and Methodology
                        Division.

                        Alternatives to the Current Method of Computing Beneficiary Coinsur-
       Health           ance for Outpatient Surgery*
                        Analysis of Initiatives to Increase Provider Participation in Medicaid
                        Analysis of Medicare’s Automated Data ProcessingSystem*
                        AssessingPRO Review of Ambulatory Surgery Under Medicare by Ana-
                        lyzing Patient-Reported Outcomes-Development and Testing of a
                        Patient Survey Instrument* +
                        Characteristics of the Uninsured in Michigan and Other SelectedStates

                        Comparative Analysis of Hospital Costs and Revenues*
                Y       Costsof Home Dialysis When Paid on a ReasonableCharge Versus Pro-
                        spective Rate Basis*



                        Page 48                            GAO/HRD-90-56   Aging Issues in Nscal Year 1989
Effects on Medicare and Beneficiary Costsof Implementation of Durable
Medical Equipment Fee Schedule**
Evaluating the Relative Effectiveness of Alternative Medical Review
Protocols* +
Evaluation of Impact of Medicare Secondary Payer Provisions on Dis-
abled Beneficiaries**
Evaluation of the Existing Hospital Cost Reporting System and the Costs
and Benefits of the Reporting System Developedin the Required Demon-
stration Project**
FnA’sSystem and Proceduresfor Assuring the Safety and Effectiveness
of Medical Devices*+
Identification of Characteristics of Rural Hospitals Vulnerable to Clo-
sure and Impact of Loss of Serviceson Community and Federal Reim-
bursement Systems*
Identification of Federal, State, and Hospital-Specific Programs/Strate-
gies Addressing Problems for Rural Hospitals*

Identifying Goals and Information Needsfor Effective Health Care Deci-
sions* +
Impact of Applying Home Health Cost Limits by Discipline**
Impact of Changesin the Medicare Part B Appeals Process*
Impact of UncompensatedCare and Changesin the Nature of Emer-
gency Patient Loads on Major Urban Area Hospitals*

Medicare Carriers and PROS and State Medicaid AgenciesNeed to
Exchange Information on Problem Providers
Medicare Reimbursementsfor Conventional EyeglassesFollowing Cat-
aract Surgery*
Medigap Insurance and Employer Maintenance-of-Effort Actions Under
Medicare Catastrophic Coverage*
Quality Assurance Issuesin Expanding Health Coverage**+


Page49                             GAO/MU)-90-56AgingIssuesinFiecalYearl989
    AppandixN
    Ongoing GAO Work as of September 90,19@9,
    Itelating to Issuea Affecting the Elderly




    Quality Assurance Under Arizona’s Long Term Care Medicaid Demon-
    stration Project*
    Quality of Care of ScreeningMammography in Different Settings
    Review of Denials by Medicare Intermediaries of Home Health Care
    Claims*
    Review of HCFAOversight of State Income Eligibility Verification System

    Review of Home Health Agency Certification Including the OBRA 1987
    Changes*
    Review Implementation of Medicare Insured Group Demonstration
    Projects**
    Review of Independent Clinical Laboratories’ Profits under the Medicare
    Fee Schedule**
    Review of Legislative History of the Current Medicare Reimbursement
    Methodology for Risk-BasedHMOS*
    Review of Medicaid-Funded HMOSin the Chicago Area*

    Review of Medicare Payments to Anesthesiologists**
    Review of Medicare’s Professional Review Organization Program for
    Health Maintenance Organizations*
    Review of Methodological Soundnessand Technical Adequacy of
    Clinical Trials Performed in Connection with Drug Applications Submit-
    tedto FDA*+
    Review of Quality Assurance Requirements and Practices for Health
    Care Delivered in Nonhospital Settings*
    Review of the Appropriateness of Medicare Payments for Durable Medi-
    cal Equipment*
    Statistics on the Medicare Part B Administrative Law Judge Hearings
P
    Process




    Page 50                                     GAO/HRLb99-56
                                                           AgingIssues   in F’bcal Year 1989
    Appendix N
    Ongoing GAO Work as of September 90,1999,
    Iblathg  to Iuuee Affecting the Elderly




    Survey of Alternatives for Increasing Accessto Nursing Homes for
    Medicaid Beneficiaries*
    Survey of Cost and Use of Contracting with Noncertified Nursing Agen-
    ties to Provide Medicare Home Health Services*
    Survey of Drug Acquisition Costs and Overhead Costsof Retail
    Pharmacies**
    Survey of Effects of Employer and Insurer Health Insurance Coverage
    Initiatives on Employees*
    Survey of FDA's Drug-Application ProcessingSystems

    Survey of Medicaid Third Party Recovery Issues
    Survey of Medicare’s HMORate Setting Methodology**

/   Survey of Recoveriesin Michigan for ServicesCoveredby Private
I   Insurers*
    Survey of the Paperwork Requirements Associated with Medicare
    Claims*

    Survey of Transfer Problems Associated with the Expanded Skilled
    Nursing Facility Benefit Under the Medicare Catastrophic CoverageAct
    of 19@3**
    Survey of WholesalePricing Practices of Prescription Drug
    Manufacturers*




    Review of the Elderly’s Use of Housing Vouchers as Compared With
    Other Forms of Assisted Housing*
    Review of the Chronically Mentally Ill in Public Housing and Their
    Impact on Elderly Tenants*




    Page 51                                     GAO/HRD-90-56   Aging Issues in Fiscal Year 1989
                                                                                                             -
                   Appendix N
                   Ongoing GAO Work as of Ssptember 89,1989,
                   Relating to Issues AfYecting the Elderly




                   America’s Underclass:Size,Causes,and Cures
Il/lcomeSecurity
                   Benefit Distribution in Small and Large Employers’ PensionPlans**
                   Comparing Vesting Status Under the Tax Reform Act of 1986 Rules and
                   Analysis of Impact of Top-Heavy Minimum Benefit and Contribution
                   Rules**
                   Demographic and Economic Characteristics of Social Security Disability
                   Program Participants: Observations and Policy Implications*
                   Effect of Tax Reform Rules on Workers’ Pension Benefits
                   Effects on Social Security, Unemployment Insurance, and Federal
                   Budget of Misclassifying Employees as Independent Contractors
                   Effects of Tax Reform Rules on Workers’ Pension Benefits**

                   Evaluation of Staffing and Productivity IssuesInvolving SSA’S
                                                                               Office of
                   Hearings and Appeals*
                   IRS Enforcement of the Employee Retirement Income Security Act of
                   1974
                   Leveraged Buy-Outs’ Effect on Pension Benefit Security*

                   Offsetting Excise Tax Rates for a Small Sample of Pension Plan Spon-
                   sors Who Terminated Overfunded Plans for Reversions*
                   Review of Employers’ Implementation of Retirement Equity Act’s Rules
                   on Survivor Pension Plan Benefits*
                   Review of the Extent that Employers Provide Retiree Health Benefits*
                   Review of the Extent that Private Employers Provide Retiree Health
                   Benefits Through Multiemployer Plans*
                   Social Security Independence-Effectiveness of Board Leadership*

         Y
                   SomeProvisions in Retiree Health Plans Overlap Provisions in the Medi-
                   care Catastrophic CoverageAct of 1988*
                   ss~/1RSCooperative Efforts to ResolveUncredited Earnings Cases*


                   Page 52                                     GAO/HRD=99-56   Agiug Issues in Fiscal Year 1989
     b
                                                                                                         -




                   Appendix N
                   Ongoing GAO Work as of &ptember        30,1989,
                   aelating to Issuea Affecting the Elderly




                   Study of Tenant Income Reporting and Verification in HUDAssisted
                   Housing*
                   Survey of Black Lung Benefits Program
                   Survey of Employee Stock Ownership Plans as a DefenseAgainst Corpo-
                   rate Takeovers
                   Survey of Feasibility of Enhancing SSA'SEnumeration Verification Sys-
                   tem to Detect Dual Welfare Benefit Claims
                   Survey of Improvements Neededin SSADebt ManagementSystems
                   Survey of SSA Death Notice Procedures
                   Survey of the Accuracy of the Answers Provided via SSA’S
                                                                          800 Tele-
                   phone Service*
                   Survey of the Activities of the Social Security Protection Bureau*

                   Survey of the Nature and Extent of SSAOutreach Activities*

                   Survey of the Pension Benefit Guaranty Corporation’s Benefit Approval
                   Process*
                   Tax-Recapture from the l&Percent Excise Tax on PensionAssets
                   Reverting to Plan Sponsors
                   Testimony on Nonqualified Deferred CompensationProvisions of the
                   Tax Code as Related to Collecting Social Security Taxes*
                   The Results of SSA’S Efforts to Telephone Employers to ResolveWage
                   Reporting Errors*
                   What Are the Alternatives to the Combined Annual WageReporting
                   Process?

                   Americans with Disabilities Act
Social and Other
Services ’         An Analysis of Alternative Methods for Defining a Household Within
                   the Food Stamp Program



                   Page 53                                           GAO/HRD-90-50   Aging Issues in Fiscal Year 1989
           AppendtxN
           Ongoing GAO Work as of September 30,1989,
           Relating to Issues Affecting tlw Elderly




           Elderly Community Services*
           Food and Nutrition Problems on Indian Reservations

           Implementation of Commodity Distribution Reform Provisions
           Review of the General Managementof HHS
           Review of Intrastate Funding Formulas Used to Distribute Title III Older
           Americans Act Funds*
           Review of Internal Control WeaknessAssociated with Food Stamp
           Issuanceand Redemption
           Review of IRS’s Implementation of Its Integrated Test Call Survey
           System
           State In-Home Servicesfor the Elderly*

           Survey of Low Income Home Energy Assistance Program Block Grant*

           Effect of Staffing Shortageson VA'SBudget and Health Care Delivery
Veterans
           Evaluation of VA'SProgram for HomelessChronically Mentally Ill
           Veterans*
           Evaluation of VA'SProcessingof Appealed Benefit Claims*
           Evaluation of VA'SEstimates of the Demand for and Supply of Nursing
           Home Beds*
           Evaluation of VA'SImplementation of Public Law 99-272 to Identify and
           Collect Medical Care Costs from Private Health Insurers*
           Examination of the Financial Statements of the VA for Fiscal Year 1989
           Financial ManagementReview of the VA

           HCFA'Sand Joint   Commissionon Accreditation of Health Care Organiza-
           tions Efforts to Assure Hospitals Meet Medicare’s Requirements*




           Page 54                                     GAO/HRD-90-56   Aging Issues in Fiscal Year 1989
        How DoesVA Assure That Veterans in Its Psychiatric Facilities Receive
        Quality Care?
        Monitoring of VA Mortality Study Follow-up*
        Quality of Care IssuesRaisedby Nurses at VA'SAlbuquerque Medical
        Center*
        Recovery of Copayments from Veterans Receiving Medical Care and VA
        Facilities*
        Review of HCFA'SProcessfor Validating the Joint Commissionon
        Accreditation of Health Care Organizations Accreditation of U.S. Hospi-
        tals Receiving Medicare Benefits
        Review of Staffing and Use of Resourcesat Military Hospitals*

        Review of VA's Ability to Assessthe Quality of Care Provided in State
        Veterans’ Homes*

        Study of the VA'SInfection Control Program*

        Survey of Medical Reports Used for VA Disability Compensation Eligibil-
        ity Determinations*

        Survey of Medical Technicians Acting as Providers in DODOutpatient
        Treatment Facilities
        Survey of the Present Supply of Nurses in U.S. Labor Force and Effect
        of Permanent and Temporary Foreign Nurses*
        Termination of VA Benefits to DeceasedBeneficiaries


        FAA’s Age 60 Rule for Commercial Pilots
Other




        Page65                             GAO/~99-66   Aging Iseues in FUcal Year 1989
 ,
 I
A3pendix V

Other FiscallYear 1989 Activities by GAO        * !
Officials Relating to IssuesAffkcting the Elderly 1
I
                 During fiscal year 1989, GAO officials spoke or published 39 times on
                 issuesrelating to aging: 18 times on health, 17 times on income security
                 issues,twice on social services,once on housing, and once on age dis-
                 crimination Specifically, we presented 22 papers, published 7 articles
                 and chapters in books, participated in 6 panels, and were interviewed on
                 4 radio and television programs.


                 icy Issues:Impact on Nursing,” at the annual meeting of the Association
                 of State and Territorial Directors of Nursing, Honolulu, April 26, 1989.
                 JamesCantwell, Human ResourcesDivision, discussed“Medicare and
                 HMOS: What Have We Learned From Five Years of Research?”at the
                 meeting of the American Public Health Association, Boston, November
                 16-17, 1988.
                 Mary Ann Curran, Human ResourcesDivision, discussedGAO'S reviews
                 of actions by the Health Care Financing Administration and the Joint
                 Commissionon the Accreditation of Healthcare Organizations to assure
                 quality of care in hospitals, at the annual meeting of the Association of
                 Health Facility Licensing and Certification Directors, Orlando, Florida,
                 October 13, 1989.
                 Terry Davis, Human ResourcesDivision, spoke on GAO'S use of national
                 health data basesin its reviews of Medicare payment policies, at a data
                 baseusers conferencesponsoredby the Health Care Financing Adminis-
                 tration, in Baltimore’, June 16, 1989.

                 Linda Demlo, Program Evaluation and Methodology Division, discussed
                 implications for research and policy at a conferenceon “Measuring
                 Health Care Effectiveness: The Use of Large Data Sets for Technology
                 Assessmentand Quality Assessment,” sponsoredby the International
                 Society for Technology Assessmentin Health Care, Washington, DC.,
                 September8, 1989.
                 Gerald Dillingham and JamesSolomon,Program Evaluation and Meth-
                 odology Division, are coauthors of the article, “Medicare’s Outpatient
                 Prescription Drug Benefit,” in the winter 1989 issue of the Pride Insti-
             Y
                 tute of Long-Term Health Care.

                 Darryl Dutton and David Lewis, Los Angeles Regional Office, spoke on
                 GAO'Smission and responsibilities and its reviews of health related


                 Page66
          other Flacxl Year 1899 Actlvltles    by GAO
          ofxldalo ltelatlug to Ioslles AfMthg
          the Elderly




          issues,before the Institute of Internal Auditors, in Los ‘Angeles,January
          24, 1089.
          Mitchell Karpman and Timothy Armstrong, Program Evaluation and
          Methodology Division, presented a paper, “The Relationship Between
          Health Status, Social Support, and Health Beliefs on Physical Activity in
          the Healthy Elderly,” at the annual meeting of the American Public
          Health Association, Boston, November 16, 1988.
          SusanLabin, Program Evaluation and Methodology Division, discussed
          GAO'Sbriefing report, Medicare: Catastrophic Illness Insurance, (GAO/
          PEMPST-B~BR, July 30, 1087), and state catastrophic illness programs,
          before the American SociologicalAssociation, Atlanta, August 26,1988.
          Marsha Lillie-Blanton, Human ResourcesDivision, spoke on
        . “Medicare and Medicaid Program Barriers in Meeting Minority Health
          Care Needs,” before the First National Conferenceon Accessand Health
          Care Financing Alternatives for Minorities, sponsoredby HHS'SOffice of
          Minority Health, Washington, D.C., September 11, 1989.
        . “Rural Hospital Closures” before the Comptroller General’s Health
          Advisory Committee, Washington, DC., May 17,1989,
          Sushi1Sharma, Program Evaluation and Methodology Division, is author
          of a chapter, “Attritions in the Baltimore Longitudinal Study of Aging
          During the First Twenty Years,” in the text Special ResearchMethods
          for Gerontology,
          Janet Shikles, Human ResourcesDivision, was interviewed on GAO'S
          report, Board and Care: Insufficient AssurancesThat Residents’ Needs
          Are Identified and Met (GAO~HRD-89-60,Feb. 10, 1989), by WWJ radio,
          Detroit, April 12, 1989.
          Sheila Smythe, Human ResourcesDivision:

    l     spoke on “Shaping a System for Universal Accessto Health Care,”
          before the annual conferenceof the Task Force on Life and the Law,
          New York, May 16,198O.
    l     participated in a panel on “Changes in the Health Care System: Implica-
          tions for Government.” 60th national conferenceof the American Soci-
.         ety for Public Administration, in Miami, April 8-12, 1989.




          Page 67                                       GAO/HRD-99-56   Aging Issues in Fiscal Year 1999
i

    I
                        Appendix V
                        Other IUcal Year 1999 Activities  by GAO
                        omcialo Relating to Iooueo &4ffectlng
                        the Elderly




                      . participated in a panel on “Health Care-Quality, Access,and Cost-
                        and the Value of Caring,” sponsoredby the University of Colorado and
                        the Rocky Mountain Health Care Corporation, Denver, October 27, 1989.

                        Elizabeth Wennar and Marsha Lillie-Blanton, Human ResourcesDivision,
                        spoke on GAO'Sreviews of issuesaffecting rural hospitals, before the
                        annual meeting of the Rural Health ResearchCenters, sponsoredby the
                        Office of Rural Health Policy, Rockville, Maryland, May 22, 1989.

                        Fred Wiener and Karyn Bell, Chicago Regional Office, discussedrural
                        hospital closures and the impact on accessto care, before the Illinois
                        Governor’s Health Care Summit on Medicaid Reform, Chicago, May 19,
                        1989.

                        Mark Rom, Program Evaluation and Methodology Division, presented a
vousing
!                       paper, “Federalism, Welfare Policy, and Residential Choice,” at the
                        Association for Public Policy Analysis and Management’snational
                        research conference,Seattle, October 27-29,1988.

                        Joseph F. Delfico, Human ResourcesDivision:
Income Security
                  l     discussed“Social Security and the Deficit,” before students and faculty
                        of the Master of Public Administration program at the Rio Pedras cam-
                        pus of the University of Puerto Rico, April 20, 1989.
                  l     spoke on “Financing Retiree Health Plans,” before the Washington Jour-
                        nalism Center, Washington, D.C., January 26, 1989.
                        Burma Klein, Human ResourcesDivision, discussedGAO'Stestimony,
                        Future Security of Retiree Health Benefits in Question (GAO/T-HRD-88-30,
                        Sept. 16, 1988), at a policy forum sponsoredby the Employee Benefits
                        ResearchInstitute, Washington, D.C., October 6, 1988.
                        Daniel McCafferty, Cincinnati Regional Office, spoke on GAOreviews of
                        the disability review process,before the regional conferenceof the
                        National Association of Disability Examiners, Columbus, Ohio, May 6,
                        1989.
                        Cynthia Maher, Human ResourcesDivision, participated in a round table
                        discussionon “Company Actions to Limit Retiree Health Costs,” before
                        AARP’s National Legislative Council, Dearborn, Michigan, August 2,
                        1989.


                        Page 58                                    GAO/HRD-99-56   Aglng Issues in F’iscal Year 1999
    Appendix V
    Other Fiscal Year 1989 Activities     by GAO
    officials  Relating co Ioslles AfYecting
    the Elderly




    Donald Snyder, Human ResourcesDivision:
    spoke on “Retiree Health Benefits: More Costly Than Pensions?” at the
     1989 Health Care Compliance Conference,Chicago,September 18, 1989.
    is the author of a chapter, “Measuring Corporate Liabilities,” in the
    Bureau of National Affairs’ publication, Retiree Benefits: The Complete
    Guide to FASB Compliance & Health Care Cost Control.
    discussed“The Funding Dilemma,” at a conferenceon the retiree health
    care crisis, sponsoredby the University of California, Los Angeles, Insti-
    tute of Industrial Relations, January 23, 1989.
    is the author of an article, “A Data Basewith Income and Assets of New
    Retirees by Raceand Hispanic Origin,” published in the spring 1989
    Review of Black Political Economy.
    is the author of an article, “The Benefits and the Costs,” published in
    Institutional Investor’s, July 1989 Retiree Health Benefits Forum.
    Lawrence H. Thompson, Human ResourcesDivision:

    participated in a panel on “Can We Afford to Age?” in “FutureView: The
     1990s and Beyond,” the sixth general assembly of the World Future
    Society, Washington, DC., July 16-20, 1989.
    discussedlegislation to put Social Security on an off-budget status, on a
    call-in television program, “Ask Senator Heinz,” carried on cable TV sys-
    tems throughout Pennsylvania, April 18, 1989.
    discussedGAO'Sreport, Social Security: The Trust Fund Reserve
    Accumulation, the Economy, and the Federal Budget (GAO/HRD-89-44,
    Jan. 19, 1989) on a call-in radio show on WARM,Wilkes-Barre, Penn-
    sylvania; and was interviewed by CBSradio news, Detroit.
.   participated in a panel discussionon “Should Accrual Accounting Be
    Used to RecognizeFederal Retirement Costs?” in the American Associa-
    tion for Budget and Program Analysis fall symposium on “Good Budget-
    ing Is Good Government,” Washington, DC., November 3, 1988.
    was interviewed for CNN’s nightly businessnews program on the
    unfunded liability for retirees’ health benefits, September 16, 1988.
    spoke on retiree health liabilities in the session“Issues in Employer
    Health Benefits” of The Foundation of Health ServicesResearch,Chi-
    cago,June 19,1989,
    Mark Rom, Program Evaluation and Methodology Division, authored
    “The Family Support Act of 1988: Federalism, Developmental Policy,
    and Welfare Reform,” Publius, Summer 1989, and coauthor of “Federal-
    ism, Welfare Reform, and Residential Choice,” in the fall 1989 American
    Political ScienceReview.


    Page 69                                           GAO/HRD-90-56   Aging Issues in Fiscal Year 1989



                                   N.
                                   :“’       (         l,                                        :i
                                   4.                                                           ‘d
                                        I,       i,
                  Appendix V
                  Other F&al Year 1989 Activities by GAO
                  Officials Relating to Issues Affecting
                  the Elderly




                  Deborah Ritt and Carolyn Boyce, Resources,Community and Economic
Social Services   Development Division, moderated panels on food and nutrition on Indian
                  reservations and conducted focus group discussionswith Indian recipi-
                  ents of federal food assistanceat the Fort Berthold, Navajo, Pine Ridge,
                  and White Earth Reservationsduring June and July 1989.
                  Ben Ross,Human ResourcesDivision, and Peter Plumeau, Albany Sub-
                  Office, discussedGAO'Sreview of support servicesfor the homelessmen-
                  tally ill, before the National Association of State Mental Health Program
                  Directors, Arlington, Virginia, December13, 1988.

                  Linda Morra, Human ResourcesDivision, spoke on “The Quality of
(Xher             EEOCand State Agencies’ Investigations of Employment Discrimination
                  Charges,” before faculty and students at the Mayaguez campus of the
                  University of Puerto Rico, April 26, 1989.




        Y




                  Page 60                                  GAO/HRD-90-56   Aging Issues in Fiscal Year 1999
ndix VI

i0 Activities Affixting Older W&km&


                  GAOappointed 726 persons to   permanent and temporary positions dur-
                  ing fiscal year 1989, of whom 123 (17 percent) were age 40 and older. Of
                  GAO'Stotal work force of 6,627 on September30, 1989,3,095 (55 per-
                  cent) were age 40 and older.
                  GAOemployment policies prohibit    discrimination basedon age.GAO'S
                  Civil Rights Office continues to (1) provide information and advice and
                  (2) processcomplaints involving allegations of age discrimination.
                  GAOcontinues to  provide individual retirement counseling and preretire-
                  ment seminars for employeesnearing retirement. The counseling and
                  seminars are intended to assist employeesin
              .   calculating retirement income available through the Civil Service and
                  Social Security systems and understanding options involving age,grade,
                  and years of service;
              .   understanding health insurance and survivor benefit plans;
              .   acquiring information helpful in planning a realistic budget based on
                  income, tax obligations, and benefits, and making decisions concerning
                  legal matters;
              .   gaining insights and perspectives concerning adjustments to retirement;
              .   increasing awarenessof community resourcesthat deal with preretire-
                  ment planning, secondcareer opportunities, and financial planning; and
              .   increasing awarenessof lifestyle options available during the transition
                  from work to retirement.




          Y




                  Page 61                            GAO/HRD-BO-66Aging   IssuesinFiscalYear1989
  Appendix VII                                                                                         w

  Major Contributors to This Report                                                                              I
\                                                                                                                p

                          Cynthia A. Bascetta, Assistant Director, (202) 276-0624
  kuman Resources         SusanE. Arnold, Assignment Manager
  Division, Washington,   Eleanor L. Johnson, Evaluator-in-Charge
  pc . .




                          Page 62                            GAO/IiRD-96-66   Aging Issues in Fiscal Year 1989
   (loaaas)



                                            ‘i