oversight

Major Management Challenges and Program Risks: Department of Health and Human Services

Published by the Government Accountability Office on 1999-01-01.

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

               United States General Accounting Office

GAO            Performance and Accountability
               Series




January 1999
               Major Management
               Challenges and Program
               Risks
               Department of Health and
               Human Services




GAO/OCG-99-7
GAO   United States
      General Accounting Office
      Washington, D.C. 20548

      Comptroller General
      of the United States



      January 1999
      The President of the Senate
      The Speaker of the House of Representatives

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

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

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

The performance and accountability series was done at
the request of the Majority Leader of the House of
Representatives, Dick Armey; the Chairman of the House
Government Reform Committee, Dan Burton; the
Chairman of the House Budget Committee, John Kasich;
the Chairman of the Senate Committee on Governmental
Affairs, Fred Thompson; the Chairman of the Senate



            Page 2                GAO/OCG-99-7 HHS Challenges
Budget Committee, Pete Domenici; and Senator Larry
Craig. The series was subsequently cosponsored by the
Ranking Minority Member of the House Government
Reform Committee, Henry A. Waxman; the Ranking
Minority Member, Subcommittee on Government
Management, Information, and Technology, House
Government Reform Committee, Dennis J. Kucinich;
Senator Joseph I. Lieberman; and Senator Carl Levin.

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




David M. Walker
Comptroller General of
the United States




            Page 3                GAO/OCG-99-7 HHS Challenges
Contents



Overview                                            6

Major                                              12
Performance and
Management
Issues
Related GAO                                        47
Products
Performance and                                    51
Accountability
Series




                  Page 4   GAO/OCG-99-7 HHS Challenges
Page 5   GAO/OCG-99-7 HHS Challenges
Overview



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

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


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                    Overview




                    identified by GAO and HHS’ Office of Inspector
                    General (OIG).


The Challenges

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




                    Page 7                GAO/OCG-99-7 HHS Challenges
                       Overview




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


Program Integrity Is   Maintaining the integrity of HHS’ large
a Continuing           programs, especially Medicare, continues to
Challenge for HHS      be a challenge. In the past, we have
                       designated Medicare as a high-risk area, and
                       it remains one. Although legislation has been
                       enacted in the past 2 years to bolster the
                       Health Care Financing Administration’s
                       (HCFA) oversight capability, initiatives to
                       curb fraud, waste, abuse, and
                       mismanagement have been slow to develop.
                       Specifically, HCFA has been slow to
                       implement its new authority to perform


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               Overview




               Medicare payment safeguard activities. In
               addition, the implementation of new
               payment systems that are intended to curb
               rapid spending increases in the Medicare
               program have been stalled because HCFA
               needs to get its critical data systems ready
               for the year 2000. Furthermore,
               implementation difficulties threaten the
               success of HCFA’s Medicare+Choice program.
               HHS’ financial statement audits also continue
               to have problems. Specifically, HHS’ inability
               to provide adequate support for certain
               financial statement amounts, such as
               Medicare accounts receivable and grant
               accrual expenses, contributed to the OIG
               issuing a qualified opinion on HHS’ fiscal year
               1997 financial statements. In addition, the
               OIG reported that HHS and its operating
               divisions do not have a fully functional
               integrated financial reporting system capable
               of producing complete and reliable financial
               statements in a timely manner.


Progress and   As required by the Government Performance
Next Steps     and Results Act of 1993, commonly known
               as the Results Act, HHS submitted to the
               Congress a strategic plan for fiscal years
               1998-2003. While this 5-year plan and the
               Department’s 1999 performance plan provide
               general information about how HHS intends


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Overview




to address these challenges, HHS needs to do
more to ensure that its programs achieve
intended results and that it is an effective
steward of taxpayer dollars.

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

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



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Overview




a comprehensive strategy for addressing
Year 2000 compliance problems.

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




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Major Performance and Management
Issues


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

            Managing these diverse and complex
            programs is a challenge for HHS, and recent
            legislative initiatives have intensified this
            challenge. For example, to implement
            welfare reform under the Personal
            Responsibility and Work Opportunity Act of
            1996 and subsequent legislation, HHS must
            give states program flexibility while
            maintaining adequate oversight. The
            Balanced Budget Act of 1997 (BBA) and the
            Health Insurance Portability and
            Accountability Act of 1996 (HIPAA) gave HCFA
            important new resources and tools for
            oversight of its Medicare program, but these
            acts also expanded the agency’s role to
            include significant responsibilities HCFA had
            not previously performed. At the same time,
            HHS must find a timely resolution to the Year



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2000 computer problem to ensure the
continued availability of benefits and
services for Medicare and Medicaid
beneficiaries. Furthermore, the solvency of
Medicare’s Hospital Insurance Trust Fund,
which funds Medicare part A, is at risk. The
Fund’s trustee board projected in its 1998
annual report that the Trust Fund will be
depleted by 2008.

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




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                 Issues




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

                 HHS’ strategic and performance plans
                 provided an opportunity for HHS to
                 demonstrate how it will coordinate its
                 diverse programs to achieve common
                 objectives. HHS’ strategic plan acknowledges
                 the need for coordination among the
                 Department’s operating divisions and
                 describes a range of approaches for


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                       improving internal coordination. However,
                       while the plan also mentions the need to
                       coordinate with state, local, and tribal
                       governments; contractors; and private
                       entities that HHS relies on as program and
                       information partners, it does not specify how
                       HHS would do so.



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

                       Implementing welfare reform exemplifies
                       the coordination challenges HHS faces. The
                       principal responsibility for carrying out the
                       legislation rests with the Administration for
                       Children and Families (ACF). In addition to


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

HHS’1999 performance plan has a general
discussion of the need for internal and
external coordination, but details about
coordination efforts were left to individual
agency plans. While some agencies’ plans
carefully delineate coordination efforts,
others do not provide sufficient information


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                    Issues




                    to allow the Congress to assess whether
                    their activities will be adequately
                    coordinated internally and externally. For
                    example, it is not clear how numerous HHS
                    programs will coordinate efforts to
                    accomplish the President’s stated goal of
                    reducing smoking among young people by
                    50 percent by 2003—a goal HHS adopted.
                    According to its strategic plan, HHS plans to
                    achieve this goal through research support
                    by the National Institutes of Health;
                    prevention activities by the Indian Health
                    Services (IHS), the Centers for Disease
                    Control and Prevention (CDC), and the Health
                    Resources and Services Administration;
                    enforcement efforts by the Food and Drug
                    Administration (FDA); and technical
                    assistance to states by the Substance Abuse
                    and Mental Health Services Administration
                    (SAMHSA). However, of the agencies that were
                    identified as contributing to this effort, only
                    FDA and IHS acknowledged in their
                    performance plans that they would
                    coordinate their work with the other
                    agencies.


Balancing Program   In administering programs that are the joint
Flexibility and     responsibility of state governments or that
Oversight           involve local grantees, HHS must continually
                    balance program flexibility with maintaining


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program controls. With welfare reform and
other recent legislation, states received
greater flexibility in designing and
implementing their assistance programs
within federal guidelines. However, at the
same time, HHS is responsible for ensuring
states comply with federal laws and
regulations. The new welfare law also gives
HHS authority to impose penalties if states
fail to comply with certain requirements and
provide bonuses if states meet certain
performance standards.

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


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making decisions about Head Start policy.
We also found that Head Start could do more
to ensure that it accurately measures the
program’s actual impact by examining
program outcomes at the grantee level.

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


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                       Issues




                       conditions that harmed residents or put
                       residents in immediate jeopardy.

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


Developing Effective   Whether a program’s goal is better nursing
Performance            home care or better preschool experiences
Measures Could         for children in Head Start, HHS needs to be
Strengthen             able to adequately measure program
Accountability
                       performance to ensure program
                       accountability. However, program scope and


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complexity—as well as various
methodological and resource
constraints—make measuring performance
difficult. For example, in measuring the
effectiveness of drug abuse treatment,
certain factors, such as reliance on
self-reported information and insufficient
client follow-up, limit confidence in the data
on treatment outcomes. Furthermore,
comparisons of study results are
complicated by differences in how outcomes
are defined and measured as well as
differences in program operations and client
factors.

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


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performance plans should include more
outcome goals to supplement output and
process goals, and they indicated that they
have begun efforts to develop them.

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




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               Issues




Key Contacts   Bernice Steinhardt, Director
               Health Services Quality and Public Health
                 Issues
               Health, Education, and Human Services
                 Division
               (202) 512-7119
               steinhardtb.hehs@gao.gov

               William J. Scanlon, Director
               Health Financing and Systems Issues
               Health, Education, and Human Services
                 Division
               (202) 512-7114
               scanlonw.hehs@gao.gov

               Cynthia Fagnoni, Director
               Income Security Issues
               Health, Education, and Human Services
                 Division
               (202) 512-7215
               fagnonic.hehs@gao.gov

               Carlotta Joyner, Director
               Education and Employment Issues
               Health, Education, and Human Services
                 Division
               (202) 512-7014
               joynerc.hehs@gao.gov




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


Balancing Flexibility   To help fulfill its oversight responsibilities,
and Accountability      HHS needs comparable and reliable data from
Creates Data            states. However, state data, where available,
Challenges              are often incomplete or inconsistent. For
                        example, HHS will use state data to ensure
                        states meet new welfare reform
                        requirements, including the 5-year time limit
                        on receiving welfare benefits. However, state


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information on the length of time an
individual has received welfare is often
unavailable or inconsistent, making it
difficult for HHS to enforce federal benefit
time limits.

HCFA  faces particular challenges in collecting
and publishing consistent information to
inform policymakers about Medicaid and the
new State Children’s Health Insurance
Program (SCHIP) created by BBA. Medicaid, a
$160-billion federal and state program,
provides health insurance coverage for
36 million low-income people—about half of
whom are children; SCHIP was established to
expand health insurance coverage for
low-income children. States have primary
responsibility for administering these
programs but share responsibility with HCFA
for data collection and management. HCFA
uses state enrollment data to create
statistical reports on Medicaid beneficiaries
served, their eligibility categories, types of
services they received, and vendor
payments. However, these data are often
inaccurate and inconsistent. For example,
while HCFA data indicate that Medicaid
enrollment has been dropping as states
implement welfare reform, our review of
these data in 16 selected states found
discrepancies between state and HCFA data.


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Similarly, state program variations
complicate uniform reporting for SCHIP. For
example, states do not have consistent
income standards for children’s enrollment
in SCHIP, and they vary in how they count
family income to determine program
eligibility. These data problems will make it
difficult to assess the impact of welfare
reform on Medicaid enrollment and the
overall effectiveness of SCHIP.

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


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                       women, to adequately estimate treatment
                       need. State estimates of drug treatment need
                       are also problematic. Although states are
                       required to report these estimates in
                       applications for federal block grant funds,
                       our review of fiscal year 1997 block grant
                       applications showed that not all states
                       submitted such data, and some submitted
                       incomplete or inaccurate data.


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

                       Detecting problems with pharmaceuticals is
                       particularly difficult. Eighty percent of bulk
                       pharmaceutical chemicals are imported. To
                       identify foreign pharmaceutical


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                   manufacturers, plan foreign inspections,
                   track inspection results, and monitor
                   enforcement actions, FDA relies on 15
                   separate automated systems, most of which
                   do not interface. As a result, essential
                   foreign drug inspection data are not readily
                   accessible to the different FDA units that are
                   responsible for planning, conducting, and
                   reviewing inspections and taking
                   enforcement actions against foreign
                   manufacturers.


Year 2000          HCFA’s automated, mission-critical systems
Challenges Put     supporting the Medicare program are not yet
Benefits and       Year 2000 compatible—and time is running
Services at Risk   out. Although HCFA recently established an
                   internal Year 2000 organization and hired
                   independent contractors to assist in
                   overseeing the Year 2000 work, we reported
                   in September 1998 that HCFA was far behind
                   schedule in repairing, testing, and
                   implementing these systems due, in part, to
                   the complexity and magnitude of the
                   problem. For example, HCFA reported that as
                   of June 30, 1998, less than one-third of
                   Medicare’s 96 mission-critical systems had
                   been fully renovated, and none had been
                   validated or implemented. (See Status of
                   HCFA’s Year 2000 Effort: Quarterly Progress
                   Report [Washington, D.C.: HHS, Aug. 15,


                   Page 28                  GAO/OCG-99-7 HHS Challenges
    Major Performance and Management
    Issues




    1998].) If not corrected, these systems could
    malfunction or produce incorrect
    information beginning in January 2000,
    putting benefits and services in jeopardy.

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

•   developing a risk-management process,
•   planning for and scheduling an integrated
    end-to-end test of all key systems to ensure
    that Medicare-wide renovations will work as
    planned,
•   ensuring that all external and internal
    systems’ data exchanges have been
    identified and agreements signed between
    the data exchange partners, and
•   accelerating the development of business
    continuity and contingency plans to allow
    time to ensure that they would be reliable
    and ready if needed.

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



    Page 29                  GAO/OCG-99-7 HHS Challenges
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                     Issues




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


HHS Plans Could      HHS’ summary overview of its performance
More Fully Address   plan discusses the Department’s reliance on
Data Problems        its partners and stakeholders for much of the
                     data that will serve to assess the results of
                     HHS programs. The plan also mentions
                     problems stemming from HHS’ use of existing
                     data systems that were established to
                     monitor the use of resources and to provide
                     aggregate output data rather than to capture
                     the outcomes of activities. However, most of
                     the plan’s discussions of data limitations do
                     not state how HHS or its agencies plan to
                     address these data problems, which could
                     undermine the credibility of performance
                     data. Furthermore, individual agencies did
                     not always provide sufficient information on


                     Page 30                  GAO/OCG-99-7 HHS Challenges
               Major Performance and Management
               Issues




               data limitations, including some data
               limitations we had identified in previous
               work, making it difficult to assess agency
               progress to overcome them.

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


Key Contacts   Bernice Steinhardt, Director
               Health Services Quality and Public Health
                 Issues
               Health, Education, and Human Services
                 Division
               (202) 512-7119
               steinhardtb.hehs@gao.gov




               Page 31                  GAO/OCG-99-7 HHS Challenges
                    Major Performance and Management
                    Issues




                    William J. Scanlon, Director
                    Health Financing and Systems Issues
                    Health, Education, and Human Services
                      Division
                    (202) 512-7114
                    scanlonw.hehs@gao.gov

                    Cynthia Fagnoni, Director
                    Income Security Issues
                    Health, Education, and Human Services
                      Division
                    (202) 512-7215
                    fagnonic.hehs@gao.gov

                    Joel C. Willemssen, Director
                    Civil Agencies Information Systems
                    Accounting and Information Management
                      Division
                    (202) 512-6408
                    willemssenj.aimd@gao.gov

Program Integrity   With their broad range of services, large
Is a Continuing     number of grantees and contractors, huge
Challenge for       volume of vendor payments, and millions of
HHS                 beneficiaries, HHS programs are attractive
                    targets for fraud, waste, abuse, and
                    mismanagement. Medicare is particularly
                    vulnerable—it pays out about $200 billion
                    annually and is responsible for financing
                    health services delivered by hundreds of
                    thousands of providers on behalf of tens of


                    Page 32                  GAO/OCG-99-7 HHS Challenges
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                       Issues




                       millions of beneficiaries. In the past, we have
                       designated the Medicare program as a
                       high-risk area, and it remains one. HHS’ OIG
                       estimated that in fiscal year 1997, HCFA paid
                       about $20 billion for fee-for-service claims
                       that did not comply with Medicare laws and
                       regulations. While the Congress has given
                       HHS new resources and authorities to
                       improve oversight of Medicare, HCFA’s
                       deployment of these tools has lagged,
                       putting on hold potential gains expected
                       from the Medicare Integrity Program,
                       Medicare’s prospective payment systems,
                       and Medicare+Choice. Furthermore, efforts
                       to streamline Medicare’s claims processing
                       system have stalled, as HCFA has focused its
                       efforts on getting the critical data systems
                       ready for the year 2000. Finally, HHS’ fiscal
                       year 1997 financial statements had serious
                       deficiencies.


HCFA Slow to           The Medicare Integrity Program created
Implement New          under HIPAA was intended to bolster HCFA’s
Authority to Perform   flagging efforts to combat fraud and abuse.
Payment Safeguard      The insurance companies HCFA contracts
Activities
                       with to process, pay, and review Medicare
                       claims are paid to review claims and detect
                       fraudulent and abusive billing practices to
                       prevent mispayments. The Congress
                       increased funding for these and other


                       Page 33                  GAO/OCG-99-7 HHS Challenges
Major Performance and Management
Issues




payment safeguard activities, appropriated
the funding in advance rather than annually,
and protected it from potential diversion by
placing the funds in a special fraud and
abuse account. In addition, the Congress
gave HCFA—through HHS—the authority to
contract with specialists to perform payment
safeguard activities.

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


Page 34                  GAO/OCG-99-7 HHS Challenges
                       Major Performance and Management
                       Issues




                       will be very limited and will not provide
                       many of the benefits initially envisioned
                       from using a specialty contractor.


Year 2000 and          Until recently, Medicare used cost
Design Challenges      reimbursement methods to pay for services
Stall Implementation   such as home health care, skilled nursing
of Medicare            facility (SNF) care, and hospital outpatient
Prospective Payment
                       services. In 1996, spending for these services
Systems
                       had reached double-digit spending growth.
                       In an effort to encourage efficient service
                       delivery and discourage rapid spending, BBA
                       mandated the design and implementation of
                       prospective payment systems (PPS), which
                       pay providers—regardless of their
                       costs—fixed, predetermined amounts that
                       vary according to patient need. Specifically,
                       BBA requires HHS—and, by extension,
                       HCFA—to implement (1) a SNF PPS, which
                       became effective in fiscal year 1998; (2) a
                       home health services PPS by fiscal year 1999
                       and an interim payment system for these
                       services, effective fiscal year 1997; (3) a
                       hospital outpatient services PPS by calendar
                       year 1999; and (4) an inpatient rehabilitation
                       services PPS by fiscal year 2001.

                       Challenges in developing and implementing
                       these systems pose significant risks:



                       Page 35                  GAO/OCG-99-7 HHS Challenges
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    Issues




•   Payment design difficulties: Under PPS, HCFA
    must carefully monitor the accuracy of data
    used to develop payment levels. It must also
    develop effective payment adjusters to
    account for the cost differences in treating
    patients who are more or less expensive
    than average to serve. Under a system of
    fixed payments, inaccurate cost data and the
    lack of an effective adjuster can result in
    underpaying or overpaying providers;
    moreover, if providers serving expensive
    patients are financially penalized, future
    access for these beneficiaries is jeopardized.
    In the case of the SNF PPS, we found that the
    methodology HCFA used to adjust rates for
    patient differences is susceptible to
    manipulation and could raise Medicare
    outlays rather than improve efficiency and
    patient care. We also found that, because the
    data used to set the prospective rates were
    not adequately audited, overstated costs of
    providing services were built into the new
    rates. Therefore, the use of these data may
    compromise the system’s ability to meet the
    twin objectives of slowing spending growth
    while promoting the delivery of appropriate
    beneficiary care.
•   Implementation delays: HCFA has announced
    that the home health PPS and outpatient PPS
    will be not be implemented by the 1999
    deadline because of the agency’s focused


    Page 36                  GAO/OCG-99-7 HHS Challenges
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                   efforts to ensure that Medicare’s multiple
                   automated systems are Year 2000 compliant.
                   The inpatient rehabilitation therapy PPS
                   could face similar delays. To the extent that
                   delays prolong the use of the existing
                   cost-based reimbursement methods or that a
                   rushed implementation builds problems into
                   a new system, Medicare will likely continue
                   to make excessive payments for services in
                   these areas.


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


                   Page 37                  GAO/OCG-99-7 HHS Challenges
    Major Performance and Management
    Issues




    information on the choices available, thus
    promoting more effective competition
    among plans.

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

•   Payment design difficulties: Medicare’s
    payment rates may overcompensate some
    plans for the beneficiaries they serve
    because the rates paid for enrolled
    beneficiaries whose expected use of health
    services is below average are not adequately
    adjusted to reflect that lower expected use.
    Although HCFA is currently working to
    develop new adjustments, as required by
    BBA, it is having difficulty collecting the
    encounter data needed to refine these
    adjustments.
•   Inadequate oversight of allowable profits:
    The BBA requirement that HCFA audit
    one-third of all Medicare managed care plans
    annually could help ensure that plans do not
    earn excessive profits on their Medicare
    contracts. However, studies by HHS’ OIG and
    others find HCFA’s current oversight in this
    area inadequate, and HCFA does not plan to
    begin these audits until 2000.
•   Faltering plan participation: Participation by
    the newly permitted types of managed care


    Page 38                  GAO/OCG-99-7 HHS Challenges
    Major Performance and Management
    Issues




    plans has not occurred as intended. To date,
    only a handful of such plans have submitted
    applications to HCFA. In addition, some of
    Medicare’s traditional managed care plans
    are pulling out of certain areas or are
    reducing covered services and increasing
    beneficiaries’ out-of-pocket costs.
•   Information campaign challenges:
    Recognizing that consumer information is an
    essential component of a competitive
    market, BBA mandated a national information
    campaign with the objective of promoting
    informed plan choice. Specifically, BBA
    requires that comparative information be
    available to beneficiaries through the
    Internet, through a toll-free telephone
    number, and in printed form by mail.
    Organizing these efforts is an enormous
    undertaking and is a new HCFA responsibility.
    The toll-free number and a beneficiary
    handbook mailing are being piloted in five
    states. Beginning in 1999, HCFA plans to
    expand its telephone information efforts
    nationwide in support of an annual
    enrollment event in November. The
    Congress’ efforts to encourage the growth of
    managed care could be thwarted if
    beneficiaries are confused, instead of
    enlightened, about their many health care
    choices.



    Page 39                  GAO/OCG-99-7 HHS Challenges
                        Major Performance and Management
                        Issues




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

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


HHS’ Financial          An area of HHS vulnerability on which HHS’
Statement Audits        OIG has reported is HHS’ difficulty in
Continue to Have        complying with the requirements of the
Problems                Chief Financial Officers Act, as expanded by
                        the Government Management Reform Act of
                        1994. HHS received a qualified opinion from
                        the OIG on its fiscal year 1997 financial
                        statements, primarily because of (1) a lack of
                        adequate supporting documentation for $2.5
                        billion in net Medicare accounts receivable;
                        (2) difficulty in determining what, if any,


                        Page 40                  GAO/OCG-99-7 HHS Challenges
Major Performance and Management
Issues




adjustments needed to be made to the
Medicare cost settlements as reported in the
fiscal year 1997 financial statements;
(3) insufficient evidence to support $2.7
billion in grant accrual expenses and a
potential net misstatement of $386 million in
grant expenses; and (4) lack of supporting
documentation for intraagency transactions.
These serious deficiencies indicate that
reliable financial management data are not
readily available to permit HHS managers to
make informed decisions. In this regard, the
OIG reported material weaknesses in internal
controls and a material instance of
noncompliance with the Federal Financial
Management Improvement Act of 1996.

Specifically, HHS’ OIG reported serious control
weaknesses affecting the reliability,
confidentiality, and availability of data
throughout the Department. It reported that
the six primary accounting systems are not
electronically linked; depend on external
sources, such as Medicare contractors, for
essential information; and cannot
automatically generate financial statements.
In addition, Medicare contractors were not
adequately protecting confidential personal
and medical information associated with
claims. As a result, contractor employees
could potentially browse data on individuals,


Page 41                  GAO/OCG-99-7 HHS Challenges
Major Performance and Management
Issues




search out information on acquaintances or
others, and possibly sell or otherwise use
this information for personal gain or
malicious purposes. Furthermore, although
HCFA had corrected weaknesses found in the
previous year, it was still possible to gain
access to HCFA’s database and modify
managed care files.

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

In addition, the fiscal year 1997 financial
statement audit again reported HCFA’s
inadequate oversight of the Medicare
program as a material weakness—one that
hampers HHS’ fiduciary responsibilities. For


Page 42                  GAO/OCG-99-7 HHS Challenges
Major Performance and Management
Issues




example, HCFA had not developed its own
process for estimating the national error rate
for improper Medicare fee-for-service
payments. For fiscal year 1997, HHS’
Inspector General estimated that about 11
percent of all Medicare fee-for-service
payments for claims, or about $20 billion, did
not comply with Medicare laws and
regulations. Similarly, we reported in our
first audit of the federal government that
problems exist in estimating improper
payments for major programs, and among
these were programs administered by HHS.

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



Page 43                  GAO/OCG-99-7 HHS Challenges
               Major Performance and Management
               Issues




               also have benefited from financial-related
               goals.


Key Contacts   William J. Scanlon, Director
               Health Financing and Systems Issues
               Health, Education, and Human Services
                 Division
               (202) 512-7114
               scanlonw.hehs@gao.gov

               Bernice Steinhardt, Director
               Health Services Quality and Public Health
                 Issues
               Health, Education, and Human Services
                 Division
               (202) 512-7119
               steinhardtb.hehs@gao.gov

               Cynthia Fagnoni, Director
               Income Security Issues
               Health, Education, and Human Services
                 Division
               (202) 512-7215
               fagnonic.hehs@gao.gov




               Page 44                  GAO/OCG-99-7 HHS Challenges
Major Performance and Management
Issues




Gloria L. Jarmon, Director
Health, Education, and Human Services
   Accounting and Financial Management
Accounting and Information Management
   Division
(202) 512-4476
jarmong.aimd@gao.gov




Page 45                  GAO/OCG-99-7 HHS Challenges
Major Performance and Management
Issues




Joel C. Willemssen, Director
Civil Agencies Information Systems
Accounting and Information Management
  Division
(202) 512-6408
willemssenj.aimd@gao.gov




Page 46                  GAO/OCG-99-7 HHS Challenges
Related GAO Products



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

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

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

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

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

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

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




                 Page 47               GAO/OCG-99-7 HHS Challenges
                Related GAO Products




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

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


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

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

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

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

                Drug Abuse Treatment: Data Limitations
                Affect the Accuracy of National and State



                Page 48                GAO/OCG-99-7 HHS Challenges
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                    Estimates of Need (GAO/HEHS-98-229, Sept. 15,
                    1998).

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

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

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


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

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

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



                    Page 49                GAO/OCG-99-7 HHS Challenges
Related GAO Products




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

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

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

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

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

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




Page 50                GAO/OCG-99-7 HHS Challenges
Performance and Accountability Series



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

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

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

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

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

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

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

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




             Page 51              GAO/OCG-99-7 HHS Challenges
Performance and Accountability Series




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

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

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

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

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

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

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

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




Page 52                     GAO/OCG-99-7 HHS Challenges
Performance and Accountability Series




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

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

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

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

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

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




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




Page 53                     GAO/OCG-99-7 HHS Challenges
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