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Transition Series 1992 [2 of 7]
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Transition Series 1992 [2 of 7]
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Michelle K. Van Cleave General Accounting Office Files
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2005-0336-F
2005-0336-F
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Science and Technology Policy, Office of (OSTP)
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Van Cleave, Michelle, Files
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General Accounting Office Files
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Transition Series 1992 [2 of 7]
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O
United States General Accounting Office
GAO
Transition Series
December 1992
Information
Management and
Technology Issues
UNITED STATES
GENERAL ACCOUNTING OFFICE
GAO/OCG-93-5TR
GAO
United States
General Accounting Office
Washington, D.C. 20548
Comptroller General
of the United States
December 1992
The Speaker of the House of Representatives
The Majority Leader of the Senate
In response to your request, this transition series report discusses
widespread weaknesses in federal information resources
management that underlie many of the problems found in individual
programs. Despite heavy investments in computer technology,
executive agencies still lack essential information for managing their
programs effectively and achieving measurable results. Moreover,
many agencies are not using information technology strategically to
simplify and streamline their organization, management, and
business processes-as well as to improve service to the public. Our
efforts have highlighted the need for better leadership and strategic
planning in this area.
The GAO products upon which this report is based are listed at the
end of the report.
We are also sending this report to the President-elect, the Republican
leadership of the Congress, the appropriate congressional
committees, and the designated heads of the appropriate agencies.
Chades A. Bousher
Charles A. Bowsher
Contents
Information
4
Management and
Technology
Issues
Lack of Essential
6
Information
Chronic Problems
10
in Developing and
Modernizing
Systems
Poor
12
Management-A
Root Cause
Problems With
19
the Acquisition
Management and
Budget Process
Solving the
23
Problem-
Managing
Strategically
Related GAO
28
Products
Page 2
GAO/OCG-93-5TR Information Management Issues
Contents
Transition Series
31
Page 3
GAO/OCG-93-5TR Information Management Issues
Information Management and
Technology Issues
The federal government spends over
$20 billion annually on new technology-and
tens of billions more running current
systems. Yet agency after agency still lacks
critical information needed to analyze
programmatic issues, manage agency
resources, control expenditures, and
demonstrate measurable results. Moreover,
the government is falling farther behind the
private sector in using information
technology to streamline its operations and
improve service to the public.
As noted in our 1988 transition series report,
these problems stem from management
weaknesses. Top federal executives
continue to overlook the strategic role of
information technology in reengineering
business practices. Moreover, information
resource managers typically lack the
authority and resources to help their
agencies modernize and simplify work
practices, define information needs, and
ensure the most effective use of information
resources. Aggravating this situation is the
federal acquisition management and budget
process. Its demand for certainty in the
system development process leads project
managers to downplay risks and
problems-resulting in missed benefits and
misspent money. Solving these problems will
Page 4
GAO/OCG-93-5TR Information Management Issues
Information Management and
Technology Issues
depend heavily on the ability of top
executives to both develop a strategic
framework for change and effectively
marshal their agencies' information
resources talent. In addition, both agencies
and the Congress need the willingness to
experiment with different approaches to the
acquisition management and budget process.
Page 5
GAO/OCG-93-5TR Information Management Issues
Lack of Essential Information
Information problems vex most federal
programs. Program managers struggle to
wrest the information they need from the
mountain of data they collect-much of it
still in paper form. Critical pieces of data are
missing, unreliable, or not suited to the
issues at hand. Even when available and
automated, the data may be scattered among
many separate information systems-making
it harder for managers to analyze complex
program problems, develop sound policies,
or measure the effectiveness of agency
actions. As a result, they may lack essential
information needed to manage effectively.
Some sobering examples follow:
Health Care: National health care
expenditures reached $666 billion in
1990-absorbing more than 12 percent of the
gross national product (GNP). Over
42 percent of this total is publicly funded. By
the end of the decade, the expenditures are
expected to exceed 16 percent of the GNP.
Poor information systems are aggravating
the current crisis in health care financing.
Medicare, for example, mistakenly paid out
over a billion dollars for services already
covered by other insurers, in part because of
inadequate data. Equally important, patient
care is still heavily dependent on paper
records that intrinsically limit the capacity to
Page 6
GAO/OCG-93-5TR Information Management Issues
Lack of Essential Information
retrieve critical data needed to guide health
care policymaking.
Education: The Department of Education,
with an annual budget of over $29 billion,
administers nearly 200 separate programs
and provides federal funds to states and
localities to educate disadvantaged children,
help persons with disabilities, and finance
the higher education of young Americans.
But the Department lacks key management
information with which to measure the
effectiveness of its programs and redirect
them as needed. For example, missing,
incomplete, and unreliable data in the
$13 billion Stafford Student Loan Program
has led the government to provide millions
of dollars in new loans to students who
previously defaulted.
Savings & Loan and Banking Crises: The
Resolution Trust Corporation (RTC),
responsible for managing and selling over
$400 billion in assets from 725 failed thrift
institutions, has had trouble effectively
executing sales strategies because it cannot
adequately track the status of assets. About
$100 billion in assets-many of which are
hard to sell-remained to be sold at year's
end. In addition, RTC could receive another
$40 billion in assets from thrifts that may fail
Page 7
GAO/OCG-93-5TR Information Management Issues
Lack of Essential Information
before September 30, 1993. Similar
information problems face the Federal
Deposit Insurance Corporation in dealing
with assets from the rising number of bank
failures.
Pulling together data from separate
information systems can be particularly
troublesome. As programmatic issues
become more interrelated, managers
increasingly need to integrate data from
across an agency in order to analyze
cross-cutting problems. The data, however,
are commonly scattered among many
independent, stand-alone information
systems, developed at different times to
meet the special needs of individual offices.
These systems usually do not employ
uniform data standards, processing
standards, or communications
standards-making the electronic exchange
of data difficult or impossible.
At the Environmental Protection Agency
(EPA), for example, various program offices
manage different kinds of pollution-such as
air, water, hazardous waste, toxic
substances, and pesticides. Over the years,
each office has developed separate
information systems to meet its particular
needs. EPA is currently struggling to integrate
Page 8
GAO/OCG-93-5TR Information Management Issues
Lack of Essential Information
data from these separate systems to better
understand and manage the interplay of
various types of pollution. Its difficulties in
doing this have weakened the agency's
ability to enforce environmental regulations
in a comprehensive manner or to pursue
complex regional pollution issues.
The effectiveness of federal programs can
also be stymied by agencies' inability to
readily share information with other units of
government and the private sector. This is
particularly evident with child support and
other welfare programs that are federally
funded but locally administered. Each year,
for example, about $4 billion in child support
payments goes uncollected. A large part of
the problem stems from difficulties that
states and federal agencies have in
exchanging data electronically on the
location of absent parents. When absent
parents cannot be found, the cost of child
support is passed on to the taxpayers.
Page 9
GAO/OCG-93-5TR Information Management Issues
Chronic Problems in Developing and
Modernizing Systems
Developing and modernizing government
information systems is a difficult and
complex process. Again and again, projects
have run into serious trouble, despite hard
work by dedicated staff. They are developed
late, fail to work as planned, and cost
millions-even hundreds of millions-more
than expected. The results, in missed
benefits and misspent money, can be found
throughout government.
During the past 25 years, for instance, the
Internal Revenue Service (IRS) has twice
tried and failed to modernize its antiquated
tax-processing system. Unreliable and
unresponsive, this system impedes IRS'
ability to collect and account for about a
trillion dollars in revenue, deal with a
reported $111 billion in accounts receivable,
and narrow the annual tax gap (the
difference between taxes owed and taxes
voluntarily paid), estimated at about
$114 billion for 1992. Although IRS now has a
vision for how it will operate in the future
and has completed basic planning for its
latest modernization effort, it has not made
satisfactory progress in some areas critical
to the project's success. For example, IRS has
been slow in finalizing a business strategy
for making the transition from its current,
paper-intensive business processes to new,
Page 10 GAO/OCG-93-5TR Information Management Issues
Chronic Problems in Developing and
Modernizing Systems
highly automated work processes-a
necessary step before the benefits of
automation can be fully realized.
Like IRS, the Social Security Administration
(SSA) has been involved in a long-term effort
to modernize its systems. For the most part,
however, SSA has focused on automating its
existing paper-driven, labor-intensive work
practices in an incremental, piecemeal
fashion. While resulting in some immediate
benefits in improved service, this approach
will not put SSA in a position to cope with the
surge in beneficiaries looming on the
horizon. To capture the critically needed
benefits of modernization, SSA must direct its
system modernization efforts toward
fundamentally improving the way it does
business. SSA is only now taking steps to
complete a business plan for guiding its use
of information technology in the future.
Page 11 GAO/OCG-93-5TR Information Management Issues
Poor Management-A Root Cause
Although information problems can be
complex and varied, they generally reflect
basic weaknesses in leadership and
organization. Top agency executives do not
pay enough attention to the role of
information technology in achieving
fundamental improvements in agency
operations. In addition, the agency unit
responsible for information resources
management (IRM) often lacks appropriate
organizational stature to be an effective
partner with top executives in identifying
opportunities to use technology to reduce
administrative costs, increase productivity,
and enhance service to the public. As a
result, agencies often initiate major
technology projects without first
determining where technology investments
can produce the greatest operational
benefits. Costly projects end up showing
disappointing results. Moreover, many
agencies have not even established
measurements for determining the actual
effects that the projects are having on
supporting mission goals.
Failure to Think
Pressure for quick solutions to complex
Strategically
problems works against strategic
planning-the heart of effective IRM. The
political process pushes both the Congress
Page 12 GAO/OCG-93-5TR Information Management Issues
Poor Management-A Root Cause
and executive agencies to focus strongly on
achieving near-term results at the expense of
the long term. So does the fact that the
average tenure of top government executives
is less than 2 years. Faced with many
competing demands and the desire to show
progress, agency leaders do not focus
enough attention on the long-term task of
simplifying and streamlining agency
operations through the use of technology.
Successful modernization is based on a
strategic analysis of what the agency needs
to accomplish, where it is now, and where it
must be at future points in order to meet its
goals. While most agencies have mission
statements that define general goals, many
agency leaders do not follow through on the
next step: analyzing current business
processes to learn where they are breaking
down and how they should be restructured
to achieve fundamental, long-term
improvements in business practices and
service to the public. Such analysis is exactly
what many successful private sector
organizations are doing.
Agencies cannot perform such analysis if
they are not disciplined enough to use
rigorous performance measures and
quantitative data to evaluate current work
Page 13 GAO/OCG-93-5TR Information Management Issues
Poor Management-A Root Cause
processes. Instead of making the effort to do
so, agency leaders too often give the green
light to technology projects in the belief that
more information resources will somehow
engender solutions to management
problems. Acquiring the latest technology
can create the illusion of progress, but
agencies may actually lock themselves more
tightly into existing, inefficient ways of doing
business.
Take, for example, the Veterans Benefits
Administration's (VBA) modernization aimed
at speeding up claims payments to veterans.
VBA did not complete its analysis of
claims-processing deficiencies before
deciding on a technology approach. As it
now turns out, VBA'S initial modernization
investment of $94 million will trim only 6 to
12 days from the average claims processing
time of 151 days-hardly an acceptable
return on investment. The problem:
Technology was focused on what turned out
to be a minor hitch in the claims process as a
whole.
Such misjudgment is not uncommon. When
an agency does not first analyze its business
processes and determine where
improvements should be focused, it
short-circuits technology's potential to
Page 14 GAO/OCG-93-5TR Information Management Issues
Poor Management-A Root Cause
dramatically increase productivity and
reduce costs. This kind of "modernization"
often does little more than speed up existing
work processes. Not surprisingly, dramatic
benefits in cost savings, productivity, and
service rarely materialize. Some
improvements are gained at the
margins-but often at a high cost.
Ineffective IRM
A strong IRM organization is an indispensable
Organization
partner in helping agency leaders work
through a top-down analysis of business
processes and determine where strategic
information technology investments need to
be made. The importance of this partnership
is recognized in the Paperwork Reduction
Act, which requires federal departments and
agencies to designate a senior official for
information resources management. This
official is to report to the agency head and,
in essence, is charged with ensuring that the
agency carries out its information activities
in an efficient, effective, economical manner.
Many agencies, however, have organized
themselves for failure in IRM. Too often, the
senior-level IRM official is a titular figure,
without experience in information
management, who is burdened with major
responsibilities in other areas. His or her IRM
Page 15
GAO/OCG-93-5TR Information Management Issues
Poor Management-A Root Cause
responsibilities become delegated to
mid-level IRM managers, who are immersed
in the agency's day-to-day systems operation
and procurement issues. Typically, these
managers do not play a major role in the
agency's high-level strategic planning. They
lack adequate organizational visibility,
authority, and competent staff resources to
ensure that program offices are using
technology to best advantage in meeting
both their own needs and the agency's
corporate information needs.
This IRM organizational problem has come
about largely because top agency leaders
have not recognized the increasingly
important role of technology in their
organizations. Historically, data processing
began as a back-room function, supporting
activities such as personnel and payroll.
Today it is still common to find an agency's
IRM function placed under a general
administrative services office, even though
computers have moved out of the back room
and onto the desks of program staff.
Poor IRM organization leads to the failure of
top management and IRM staff to work
together in developing an effective strategic
technology plan. This plan is the linchpin
that aligns an organization's business needs
Page 16 GAO/OCG-93-5TR Information Management Issues
Poor Management-A Root Cause
with its information resources. It is the map
for getting the agency from where it is now
to where it wants to be-and for defining the
technology investments that should be made
to support streamlined work processes.
Frequently, what an agency touts as a
strategic technology plan is merely a listing
of ongoing acquisitions.
Failure to align program needs with
technology investments results in lost
opportunities for improvement and wasted
dollars. For example, the National Institutes
of Health (NIH) did not effectively manage
key aspects of a major system contract,
potentially worth over $800 million. The
acquisition was not factored into NIH'S
strategic planning, nor were the computing
requirements of the scientific community
identified. The result was a contract that did
not effectively support NIH'S basic purpose:
biomedical research. Another example is the
Farmers Home Administration's (FmHA)
effort to modernize the automated systems
used to make and collect loans-its third
attempt since the mid-1970s. FmHA failed to
link its $520 million technology initiative to a
long-range business plan that clearly
articulated how the agency would operate in
the future. Indeed, the technology plan did
not even reflect important changes being
Page 17 GAO/OCG-93-5TR Information Management Issues
Poor Management-A Root Cause
made in FmHA'S organizational structure and
loan-management operations. These
problems cast serious doubt on FmHA'S ability
to use technology to better support its loan
programs.
Without strong corporate IRM leadership and
planning, program staff may develop systems
that meet their own requirements, but
conflict with the broader information needs
of the organization. The result is a
hodge-podge of incompatible standards and
systems. For example, the Navy's
$600 million program to upgrade nontactical
computers on ships lacks effective central
IRM management. Instead, 12 different Navy
commands have authority over development,
funding, and procurement of the major
computer systems that comprise the
program. The resulting redundant
development efforts require excessive
financial resources and increase the amount
of training and maintenance needed to
support the different systems.
Page 18 GAO/OCG-93-5TR Information Management Issues
Problems With the Acquisition
Management and Budget Process
Even well-planned efforts to modernize the
use of information technology can be
derailed by the federal acquisition
management and budget process. The
objectives of the process are reasonable: to
deliver individual systems that perform as
intended, on time, and cost-effectively. The
process aims to achieve economy through
standardizing and sharing systems across
agencies. Rewards are supposed to go to
project managers who can do this. Yet the
process repeatedly fails to meet these
objectives because it does not take into
account the realities of systems
development.
A fundamental dichotomy is at work in
large-scale systems development projects:
the acquisition management process
demands certainty and is risk-averse, yet
systems development is inherently uncertain
and risk-intensive. The process calls for
systems developers to formulate precise
long-term plans and budgets. It
unrealistically assumes that detailed systems
requirements can be well understood at the
outset, that software development will be
predictable, and that long-term budgeting
can be done with a high degree of accuracy.
Unfortunately, none of these expectations
Page 19
GAO/OCG-93-5TR Information Management Issues
Problems With the Acquisition
Management and Budget Process
recognizes the enormous difficulties
involved in developing large systems.
The acquisition management process often
works well for purchasing readily definable
goods and services, but it does not support
effective risk identification and risk
management-the essence of major systems
development. Large-scale systems are
extremely complex and take many years to
design, develop, test, and install. For
example, software development, which is
the heart of most system development
projects, remains a poorly managed
discipline. It is still very difficult to
accurately predict software costs,
development time, and performance at the
beginning of a systems project. Such
uncertainties make it nearly impossible to
satisfy in any meaningful way the process's
expectations for precise milestones and
budget estimates.
To make matters worse, the acquisition
management and budget process creates
behavioral incentives that actually
undermine good systems development
practices and hinder the achievement of
governmentwide objectives. For example,
the process provides powerful incentives for
project managers to set unrealistically
Page 20 GAO/OCG-93-5TR Information Management Issues
Problems With the Acquisition
Management and Budget Process
optimistic cost and schedule estimates and
to ignore risks and problems. Project
budgets are generally set by the agency, the
Office of Management and Budget, and the
Congress on a year-by-year basis. This
process often involves scrutiny of the
progress being made by the project. Because
changes in plans and cost estimates are seen
as indicators of poor management, project
managers try to maintain a pretense of
problem-free development and avoid
providing honest assessments of project
risks. By not mentioning problems for as
long as possible, managers can often ensure
continued project funding-at least in the
near term.
Since agencies frequently change project
managers, it becomes easy to defer problems
to others. This is particularly true with
Defense projects, where the rotation of
personnel into and out of project manager
positions is routine. With such managerial
turnover comes a clouding of responsibility
and accountability for the project's success,
all too often resulting in higher costs and
delays in the delivery of systems.
Because there are few incentives and many
risks in developing systems that bridge the
needs of several offices or support other
Page 21
GAO/OCG-93-5TR Information Management Issues
Problems With the Acquisition
Management and Budget Process
agencies, it is not surprising that technology
projects generally reflect the parochial
interests of individual offices. The result is
the continued spawning of systems that are
narrowly focused and cannot support the
larger needs of the agency or the
government.
Page 22 GAO/OCG-93-5TR Information Management Issues
Solving the Problem-Managing
Strategically
Managing information resources
strategically involves visionary leadership
and a framework for managing change that
focuses on the strategic uses of technology
for achieving the agency's mission. Few
other management initiatives offer higher
leverage over the cost-effective use of
taxpayer dollars. This effort needs to be
supported by a sound IRM organization.
Establishing a
Agency leaders can start by adopting a
Strategic
management philosophy that emphasizes
Framework for
continuous improvement of business
Change
practices. This philosophy is essential if
agencies are to carry out their missions
effectively during a prolonged period of
budgetary constraints.
Implementing such a philosophy requires a
strategic framework that can guide the
agency over many years, even amid turnover
in agency leadership. This framework must
necessarily be based on mission goals,
analysis of business practices, and
long-range information technology planning.
The operative concept should be simplifying
and streamlining business processes.
Developing a strategic framework should
always precede the development and
acquisition of automated systems. Without it,
Page 23
GAO/OCG-93-5TR Information Management Issues
Solving the Problem-Managing
Strategically
technology modernization invariably breaks
down into a series of half-measures that are
redirected or replaced every few years.
The Congress often focuses on the costs of
systems procurements. While costs are
important, the underlying management issue
is becoming more critical: How well do
planned information technology projects
support fundamental, long-term
improvement in agency programs,
operations, and service to the public? By
highlighting this issue as part of its oversight
activities, the Congress can encourage
agency leaders to develop and follow a
strategic framework for successful
modernization that can be sustained over
many years. The need to continuously
improve federal operations is, after all, a
shared concern that transcends shifts in
personnel or politics.
Strengthening
Sound IRM management is essential for
IRM Leadership
realizing potential productivity and
and Management
effectiveness gains achievable with today's
technology. Agency leaders need to make
their IRM organization a strong partner in
determining how information technology
should be applied to best meet the strategic
needs of the agency. Doing this involves
Page 24 GAO/OCG-93-5TR Information Management Issues
Solving the Problem-Managing
Strategically
three elements: IRM leadership, organization,
and resources.
The agency needs a senior-level IRM
executive who is familiar with the uses of
information technology in simplifying and
streamlining business practices and who can
devote full attention to this issue. This senior
executive needs to be highly placed in the
organization so that he or she can work
closely with the agency head and senior
program managers in analyzing work
processes and formulating a strategic plan
for information technology needs. Some
agencies have formalized this relationship by
establishing the position of chief information
officer, reporting directly to the head of the
organization.
Similarly, the IRM function itself needs
organizational placement that appropriately
reflects the critical role of information
technology in all aspects of agency
operations. This means moving the IRM unit
out from under general administrative
services and making it a unit of its own,
reporting to top management. It should be
headed by the agency's senior-level IRM
executive.
Page 25
GAO/OCG-93-5TR Information Management Issues
Solving the Problem-Managing
Strategically
Neither the senior-level IRM executive nor the
IRM organization can be effective without
adequate staff resources imbued with
disciplined approaches for both managing
the current technology base and carrying out
strategic planning for new technology.
Providing these resources is difficult for
agencies in lean budget times. But this is a
good place to make an investment since the
effective use of information technology can
leverage major benefits in operational
efficiency and service to the public.
Experimenting
How can the federal acquisition management
With Change
and budget process be better tailored to
accommodate the uncertainty and
complexity inherent in modern, large-scale
systems development? The stakes are high,
considering the billions of dollars involved in
these procurements, the desire to promote
competition, and the need to oversee and
control expenditures.
Resolving this issue will require the
cooperative dedication of the Congress, the
executive branch, and the technology
industry. No one has answers that satisfy
everyone's concerns. It is therefore
important that all parties involved have the
willingness and flexibility to experiment
Page 26 GAO/OCG-93-5TR Information Management Issues
Solving the Problem-Managing
Strategically
with different approaches. For example,
multiyear budgeting might be tried on some
projects to encourage managers to identify
and correct problems early in the
acquisition. Such experimentation is
particularly appropriate given the rapid pace
of innovation in information technology. It
may lead to broad-based agreement on
better acquisition management models that
could help agencies build the information
technology base they need to dramatically
improve their operations and better serve
the American people.
Page 27
GAO/OCG-93-5TR Information Management Issues
Related GAO Products
Veterans Benefits: Acquisition of
Information Resources for Modernization Is
Premature (GAO/IMTEC-93-6, Nov. 4, 1992).
ADP Procurement: Prompt Navy Action Can
Reduce Risks to SNAP III Implementation
(GAO/IMTEC-92-69, Sept. 29, 1992).
Defense ADP: Corporate Information
Management Must Overcome Major
Problems (GAO/IMTEC-92-77, Sept. 14, 1992).
Perceived Barriers to Effective Information
Resources Management: Results of GAO
Panel Discussions (GAO/IMTEC-92-67,
Sept. 1992).
Tax Systems Modernization: Update on
Critical Issues Facing IRS (GAO/T-IMTEC-92-18,
May 13, 1992).
Department of Education: Management
Commitment Needed to Improve
Information Resources Management
(GAO/IMTEC-92-17, Apr. 20, 1992).
Environmental Enforcement: EPA Needs a
Better Strategy to Manage Its Cross-Media
Information (GAO/IMTEC-92-14, Apr. 2, 1992).
Page 28 GAO/OCG-93-5TR Information Management Issues
Related GAO Products
Resolution Trust Corporation: Corporate
Strategy Needed to Improve Information
Management (GAO/IMTEC-92-38, Mar. 5, 1992).
Information Resources: Summary of Federal
Agencies' Information Resources
Management Problems (GAO/IMTEC-92-13FS,
Feb. 13, 1992).
Major NIH Computer System: Poor
Management Resulted in Unmet Scientists'
Needs and Wasted Millions (GAO/IMTEC-92-5,
Nov. 4, 1991).
ADP Modernization: Half-Billion Dollar FmHA
Effort Lacks Adequate Planning and
Oversight (GAO/IMTEC-92-9, Oct. 29, 1991).
Interstate Child Support Enforcement:
Computer Network Contract Not Ready to
Be Awarded (GAO/IMTEC-92-8, Oct. 23, 1991).
SSA Computers: Long-Range Vision Needed
to Guide Future Systems Modernization
Efforts (GAO/IMTEC-91-44, Sept. 24, 1991).
FAA Information Resources: Agency Needs to
Correct Widespread Deficiencies
(GAO/IMTEC-91-43, June 18, 1991).
Page 29
GAO/OCG-93-5TR Information Management Issues
Related GAO Products
Medical ADP Systems: Automated Medical
Records Hold Promise to Improve Patient
Care (GAO/IMTEC-91-5, Jan. 22, 1991).
Meeting the Government's Technology
Challenge: Results of a GAO Symposium
(GAO/IMTEC-90-23, Feb. 1990).
Information Technology Issues
(GAO/OCG-89-6TR, Nov. 1988).
Page 30 GAO/OCG-93-5TR Information Management Issues
Transition Series
Economics
Budget Issues (GAO/OCG-93-1TR).
Investment (GAO/OCG-93-2TR).
Management
Government Management Issues
(GAO/OCG-93-3TR).
Financial Management Issues
(GAO/OCG-93-4TR).
Information Management and Technology
Issues (GAO/OCG-93-5TR).
Program Evaluation Issues (GAO/OCG-93-6TR).
The Public Service (GAO/OCG-93-7TR).
Program Areas
Health Care Reform (GAO/OCG-93-8TR).
National Security Issues (GAO/OCG-93-9TR).
Financial Services Industry Issues
(GAO/OCG-93-10TR).
International Trade Issues (GAO/OCG-93-11TR).
Commerce Issues (GAO/OCG-93-12TR).
Energy Issues (GAO/OCG-93-13TR).
Page 31 GAO/OCG-93-5TR Information Management Issues
Transition Series
Transportation Issues (GAO/OCG-93-14TR).
Food and Agriculture Issues
(GAO/OCG-93-15TR).
Environmental Protection Issues
(GAO/OCG-93-16TR).
Natural Resources Management Issues
(GAO/OCG-93-17TR).
Education Issues (GAO/OCG-93-18TR).
Labor Issues (GAO/OCG-93-19TR).
Health and Human Services Issues
(GAO/OCG-93-20TR).
Veterans Affairs Issues (GAO/OCG-93-21TR).
Housing and Community Development
Issues (GAO/OCG-93-22TR).
Justice Issues (GAO/OCG-93-23TR).
Internal Revenue Service Issues
(GAO/OCG-93-24TR).
Foreign Economic Assistance Issues
(GAO/OCG-93-25TR).
Page 32 GAO/OCG-93-5TR Information Management Issues
Transition Series
Foreign Affairs Issues (GAO/OCG-93-26TR).
NASA Issues (GAO/OCG-93-27TR).
General Services Issues (GAO/OCG-93-28TR).
*U.S.G.P.O. : 1993-336-740 Page 33 GAO/OCG-93-5TR Information Management Issues
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United States General Accounting Office
GAO
Transition Series
December 1992
Program Evaluation
Issues
UNITED STATES
OFFICE GENERAL
GAO/OCG-93-6TR
GAO
United States
General Accounting Office
Washington, D.C. 20548
Comptroller General
of the United States
December 1992
The Speaker of the House of Representatives
The Majority Leader of the Senate
In response to your request, this transition series report discusses a
topic that is critical to the effective oversight of government
programs: the need for sound, evaluative information on how
programs are operating and what they are actually accomplishing.
This report, unlike our 1988 transition series report on this topic,
cites some examples of good work being done within executive
branch agencies. More generally, however, we feel that the attention
being paid to evaluation issues is inadequate either for managing
programs efficiently or for providing the Congress with the data
necessary for informed program oversight.
The GAO products upon which this report is based are listed at the
end of the report.
We are also sending copies of this report to the President-elect, the
Republican leadership of the Congress, the appropriate congressional
committees, and the designated heads of the appropriate agencies.
Chades Bousher
Charles A. Bowsher
Contents
The Importance
4
of Program
Evaluation
Rebuilding
7
Capacity
The Effects of
10
Many Important
Programs Are
Unknown
Some Agencies
14
Are Poorly
Informed About
Program
Targeting and
Outreach
Agencies
18
Sometimes Rely
Upon Flawed
Studies and
Ignore or Misuse
Sound Analyses
Some Promising
23
Initiatives Do
Exist
Page 2
GAO/OCG-93-6TR Program Evaluation Issues
Contents
Related GAO
25
Products
Transition Series
28
Page 3
GAO/OCG-93-6TR Program Evaluation Issues
The Importance of Program Evaluation
Over the next few years, the federal
government will face powerful opposing
pressures: the need, on the one hand, to
reduce the federal deficit, and the demand,
on the other, for a federal response to some
potentially expensive domestic problems
(expanding health insurance, restoring the
economy, and the like). These pressures are
likely to intensify concern with the effective
management of federal programs and with
the availability of objective information on
the results of federal investments. In other
words, are the federal officials who
administer programs adequately informed
about the implementation and the results of
those investments? And can they, in turn,
adequately inform the President, the
Congress, and the nation about what has
been accomplished?
Program evaluations contribute systematic
information to federal decision-making that
has been useful in a variety of ways, such as
the following:
Recent welfare-to-work evaluations funded
by the Department of Health and Human
Services showed a relationship between the
increased employment of program
participants and savings to the federal and
Page 4
GAO/OCG-93-6TR Program Evaluation Issues
The Importance of Program Evaluation
state governments achieved through reduced
welfare payments.
Evaluations of chemical weapons
demonstrated gaps in the military's capacity
to manage and use these weapons and
played a major role in the termination of the
Bigeye Bomb program and in the successful
completion of ongoing arms control
negotiations on chemical warfare.
Evaluations conducted some years ago
showed the effectiveness of the Job Corps
program in preparing disadvantaged young
men and women for employment and were a
major contributor to the reauthorization of
this expensive intervention.
The Safe Medical Devices Act of 1990
included a number of provisions that were
the direct results of findings in a series of
medical device evaluations. Among other
things, the act provides for increased recall
powers for the Food and Drug
Administration and for improved
information reported to the Congress.
It is important to recognize that an objective
and systematic evaluation function not only
serves to protect an agency against wasted
resources in the form of inefficient or
ineffective programs. There may also be
Page 5
GAO/OCG-93-6TR Program Evaluation Issues
The Importance of Program Evaluation
elements of government programs that are in
fact harmful to the well-being of some
segments of society-unintended effects that
a well-conducted program evaluation could
prevent or detect. For example, an
evaluation of the likely impacts of proposed
immigration reform legislation-suggesting
that the proposal would result in long
waiting lists and delay the reunification of
families-led to appropriate changes in the
bill before its enactment in 1990.
If the nation is to have strong, well-managed
federal programs that can deal efficiently
and successfully with our domestic and
international problems and if the President
and the Congress are to be adequately
informed of progress in meeting those
challenges, the numbers and quality of the
program evaluations conducted by executive
branch agencies must be improved.
Page 6
GAO/OCG-93-6TR Program Evaluation Issues
Rebuilding Capacity
In our 1988 transition series report, we found
that there had been a 22-percent decline in
the number of professional staff in agency
program evaluation units between 1980 and
1984. A follow-up study of 15 units that had
been active in 1980 showed an additional
12-percent decline in the number of
professional staff between 1984 and 1988.
Funds for program evaluation also dropped
substantially between 1980 and 1984 (down
by 37 percent in constant 1980 dollars). We
have not repeated this survey, but
discussions with the departments and the
Office of Management and Budget offer no
indication that the executive branch
investment in program evaluation showed
any meaningful overall increase from 1988 to
1992.
Apparently, the effort to rebuild the
government's evaluation capacity that we
called for in our 1988 transition series report
has not been carried out. As in 1988,
executive branch agencies have often failed
to conduct the program evaluations that
would provide officials with knowledge
about the effectiveness of their programs. As
in 1988, the Congress continues to turn to us
and our sister agencies-the Congressional
Budget Office, the Office of Technology
Assessment, and the Congressional Research
Page 7
GAO/OCG-93-6TR Program Evaluation Issues
Rebuilding Capacity
Service-to do studies that might more
appropriately be conducted by executive
branch agencies. It is our mission to provide
credible information to the Congress and to
help ensure that the reports the Congress
receives are not limited to those from special
interest groups. However, we should not,
and indeed cannot, do it all.
A first step in improving capacity is for
agencies to review the adequacy of their
current funding for evaluation. Some
agencies, like the Department of Commerce
and the Administration on Aging, devote few
resources to evaluating their programs.
Other agencies-like the Department of
Education and the Public Health
Service-dedicate major resources to
evaluation. In these agencies, the task may
be less one of rebuilding overall capacity
than of strengthening areas of weakness. For
example, the Department of Education
conducts many evaluations of its elementary
and secondary programs, but the investment
at the postsecondary level is irregular in
spite of some major ongoing problems.
Similarly, some Public Health Service
agencies do a great deal of evaluation,
whereas others, like the National Institutes
of Health, spend only a small percentage of
available funds for program evaluation.
Page 8
GAO/OCG-93-6TR Program Evaluation Issues
Rebuilding Capacity
Our evaluations help fill the gaps in the
information available to the Congress, but
there is no substitute for a systematically
planned, ongoing effort for an agency to
evaluate its own programs. The next
sections demonstrate that the limited
capacity for program evaluation in the
executive branch has some important
consequences:
agencies lack information on the
effectiveness of their programs;
agencies lack data on the targeting and
outreach of their programs; and
agencies need to improve their capacity to
make sound decisions on the use of data for
policy-making.
We are, however, able to conclude with
some examples of promising agency
initiatives.
Page 9
GAO/OCG-93-6TR Program Evaluation Issues
The Effects of Many Important
Programs Are Unknown
One of the most significant gaps in program
evaluation information from the executive
branch concerns program effectiveness.
Program effectiveness evaluations show
what, if anything, has changed as a result of
implementing a program. Limited budget
dollars can be more concentrated among
programs that have demonstrated
effectiveness, while programs with little
evidence of effectiveness can be cut or
reformed and restructured.
Do participants in federally funded
elementary and secondary education
programs for disadvantaged children show
improvements in educational achievement
similar to that of other children? Are federal
housing vouchers shown to be effective in
helping needy persons who would often not
have adequate housing without the
vouchers?
In short, is there evidence of some concrete
benefit that results from a program that
would not have occurred without the
program? Program effectiveness evaluations
estimate the effects of federal programs
using statistical analysis of outcomes (such
as educational achievement test scores or
condition of housing) for groups of persons
Page 10
GAO/OCG-93-6TR Program Evaluation Issues
The Effects of Many Important
Programs Are Unknown
receiving program services compared with
similar groups of nonparticipants.
Our response to congressional requests over
the last 4 years has yielded the following
information on the effects of federal
programs.
Education
Despite increased attention in recent years
to removing the barriers that prevent the full
involvement of persons with disabilities in
work and other activities, the Department of
Education has not evaluated the
effectiveness of its $1.8 billion-per-year
program of vocational rehabilitation. Our
evaluation using confidential income tax
data showed only very modest overall
long-term gains in earned income, in
contrast to the dramatic short-term
employment effects often cited by the
program. The Congress has strengthened
evaluation in the recent reauthorization of
the program. The Department of Education
should conduct such studies and help
establish the overall impact of the legislation
by identifying, for example, how people with
certain disabilities have been helped by the
program while those with other disabilities
may need different assistance than the
program has provided.
Page 11
GAO/OCG-93-6TR Program Evaluation Issues
The Effects of Many Important
Programs Are Unknown
Health and
The Department of Health and Human
Human Services
Services regularly makes public recognition
awards to "promising" drug abuse
prevention programs on the basis of reviews
that required no hard evidence of program
effectiveness. The problem here is that
people in other communities could base new
programs upon weak models while other,
more effective programs go unrecognized. In
response to our report, the agency agreed to
begin seeking such evidence.
Health and
To correct perceived widespread abuses of
Human Services
foster care, federal reforms were enacted in
1980 to ensure that the necessity and
appropriateness of each foster care
placement was periodically reviewed and
that families received needed services. A
1989 evaluation found that these reforms had
not been completely carried out and that no
national evaluations had been performed.
This evaluation gap means that children
placed in foster care may still be
unnecessarily at risk of abuses such as
needless delays in returning them to their
natural parents.
Defense
We evaluated the Department of Defense's
(DOD) methods for selecting recruits for
Page 12
GAO/OCG-93-6TR Program Evaluation Issues
The Effects of Many Important
Programs Are Unknown
training in technical occupational specialties
and for assessing the effectiveness of the
training. DOD's major selection instrument,
the Armed Services Vocational Aptitude
Battery, which has been extensively
researched over the years, was moderately
successful in predicting classroom
performance in these more demanding
training courses. But in most cases, testing
of actual field performance-the end point
of the training program-was either
nonexistent or inadequate, making it
impossible to evaluate the overall
effectiveness of the services' training
program. Thus, much of the investment that
the Department had made in program
evaluation was in this case inefficient
because the final loop-showing which
training programs produce the top
performers and thus make the best use of
DOD's human resources-had not been
closed.
Page 13
GAO/OCG-93-6TR Program Evaluation Issues
Some Agencies Are Poorly Informed
About Program Targeting and Outreach
A second type of program evaluation that is
useful-but often not available from federal
agencies-concerns questions of program
implementation. Agencies should evaluate
different aspects of program
implementation, such as the proper targeting
of programs and their outreach-that is,
whether they reach some or all of those
eligible.
Analysis of program targeting demonstrates
how well the program is reaching its
intended recipients (such as determining the
extent to which Chapter 1 aid, under the
Elementary and Secondary Education Act of
1965, is targeted for and reaches
educationally disadvantaged children).
Studies of outreach examine participation in
federal programs.
Such evaluations help agencies understand
why their outreach may not be successful
and what barriers may need to be overcome
before participation can increase. There are
important gaps in agencies' knowledge of the
targeting and outreach of their programs.
The limited executive branch evaluations of
targeting and program outreach led to
congressional requests for us to do work
such as the following.
Page 14
GAO/OCG-93-6TR Program Evaluation Issues
Some Agencies Are Poorly Informed
About Program Targeting and Outreach
Health and
The National Cancer Institute is responsible
Human Services
for disseminating information on treatments
proven to be effective in the treatment of
cancer in experimental situations. An
evaluation revealed various blockages in the
processes that the Institute used to move
breakthrough therapies from clinical trials to
the patient. Recommended treatments had
not been adopted for many patients in the
samples we studied. Consequently, these
patients had not received what the Institute
considered state-of-the-art treatment.
Education
Federal student aid is especially intended to
help persons of modest means gain access to
postsecondary education, but sound
information on school costs and the
availability of aid has to reach potential
recipients in time for them to make crucial
decisions about their higher education plans.
An evaluation documented both
unawareness and incorrect understanding of
the program that could have significant
effects on the decisions students and parents
make. The Congress acted on these findings
in revising student aid laws in 1992 to require
the Department to make improved
information available and to evaluate its
impact.
Page 15
GAO/OCG-93-6TR Program Evaluation Issues
Some Agencies Are Poorly Informed
About Program Targeting and Outreach
Agriculture
We found in reviewing the Department of
Agriculture's Food Stamp program that less
than half of the households eligible for food
stamps participated in the program in the
mid-1980s. Evaluators found evidence of a
variety of outreach problems. About half of
the eligible nonparticipants incorrectly
thought that they were ineligible. Almost
two-thirds of the eligible nonparticipants
cited either a lack of information or program
barriers, including administrative "hassles,"
as the reason for their nonparticipation.
These findings suggest that the program
should be changed to make food stamps
more available to eligible persons who need
them.
Aging
The Older Americans Act mandates that in
the provision of services, the Administration
on Aging should target older individuals with
the greatest economic or social needs and
give particular attention to low-income
minority individuals. A program evaluation
found that the data collection instrument
and methodology used by the agency did not
permit the generation of accurate counts of
all participants, including targeted
populations, in mandated programs and
services. The data are thus inadequate to
answer fundamental congressional questions
Page 16
GAO/OCG-93-6TR Program Evaluation Issues
Some Agencies Are Poorly Informed
About Program Targeting and Outreach
about the degree to which agency programs
target resources to persons with the greatest
economic or social needs.
Page 17
GAO/OCG-93-6TR Program Evaluation Issues
Agencies Sometimes Rely Upon Flawed
Studies and Ignore or Misuse Sound
Analyses
In 1992, we found some new consequences
of the deterioration of the program
evaluation capacity of the federal
government in addition to the absence of
information. In some cases, agencies have
conducted evaluation studies, but the
information produced is either flawed or
improperly used for policy purposes. The
studies may be based upon problematic data
or analysis, or they may be properly
conducted but ignored or misused in the
formulation of policy. These problems
suggest that management improvements are
necessary. Agencies need to review the
quality of their data and research more
carefully and better integrate the findings
from program evaluations and other
analyses into agency decision-making.
Examples of inappropriate use-or
neglect-of evaluation evidence by federal
agencies in recent years include the
following.
Environmental
An analysis of the shared responsibilities of
Protection
the Environmental Protection Agency (EPA)
Agency
and state environmental agencies for
managing a national program of hazardous
waste found that important information gaps
remain. Problematic measurement and data
Page 18
GAO/OCG-93-6TR Program Evaluation Issues
Agencies Sometimes Rely Upon Flawed
Studies and Ignore or Misuse Sound
Analyses
collection procedures limit the quality of
some of the information produced, and the
biennial reporting system still does not
ensure that the states will collect or report to
EPA all necessary data. The result is that it is
not possible to determine whether the
hazardous waste reduction goals are
being met.
Multiple Agencies
We conducted a comprehensive evaluation
of four executive branch agencies-EPA, the
Food and Drug Administration, the
Occupational Safety and Health
Administration, and the Consumer Product
Safety Commission-to determine how well
they were protecting the public from
exposure to reproductive and developmental
toxicants. There were major gaps in the
evaluative information available to these
agencies. First, because no accepted federal
list of these toxins has been developed, such
as that mandated for carcinogens, these
agencies have had no index of the most
important hazards to reproduction and
development. Second, risk assessment for
these toxicants has been based upon a
flawed threshold assumption: that is, that
there is a specific dose level below which no
problems occur. However, well-known
hazards, such as lead and radiation, are
Page 19
GAO/OCG-93-6TR Program Evaluation Issues
Agencies Sometimes Rely Upon Flawed
Studies and Ignore or Misuse Sound
Analyses
dangerous at any dose level. Therefore, it
appears that current standards for exposure
to lead and radiation could be resulting in
more developmental problems in children
and reproductive problems in adults than
would occur under an alternative,
nonthreshold approach.
Defense
Many unproven assumptions weaken DOD's
decision-making in important national
security areas. Our evaluation of the U.S.
strategic triad found several major examples
of assumptions that we found to be either
inaccurate or unsupported by available data.
In some areas, such as the threat posed by
the former Soviet Union, the assumptions
grossly overstated what the data actually
support. In other areas-for example, the
performance of weapon systems-available
data instead show understated assumptions.
In still other cases, such as specific
assertions made by officials, no supporting
data were available. Over the past 30 years,
DOD has not conducted any comprehensive
evaluation of the strategic nuclear triad. The
lack of realistic assessments of the threat
and the lack of rigorous analysis of the
relative performance and merit of the
weapon systems has resulted in the
Page 20
GAO/OCG-93-6TR Program Evaluation Issues
Agencies Sometimes Rely Upon Flawed
Studies and Ignore or Misuse Sound
Analyses
questionable development and procurement
of multiple costly modernization programs.
Agriculture
A series of studies examined the accuracy of
various price, production, and supply
forecasts made by the U.S. Department of
Agriculture. Long-term commodity forecasts
had large and systematic error rates over the
period 1981-88. These errors contributed to a
significant underestimate of the commodity
program outlay estimates that were made in
the President's 1990 budget submission to
the Congress. Accurate forecasts are also
important for administering such agency
programs as acreage reductions and export
enhancements. The Department agreed with
recommendations to improve forecasting
and set up a process to identify, report, and
correct errors when they occur.
Transportation
We reviewed the quality and completeness of
the analytical efforts supporting the
testimony of the National Highway Traffic
Safety Administration regarding the impact
of continued requirements for automobile
downsizing upon highway safety. The
agency's finding that more than 1,300
fatalities each year can be attributed to the
automobile weight reduction efforts that
Page 21
GAO/OCG-93-6TR Program Evaluation Issues
Agencies Sometimes Rely Upon Flawed
Studies and Ignore or Misuse Sound
Analyses
began in the 1970s was not supported by
available data. Instead, our analyses showed
that the automobile weight reductions have
had virtually no net effect on total highway
fatalities. On the one hand, the very lightest
cars have higher fatality rates than the very
heaviest. On the other hand, the decreased
number of heavy cars on the highways
accounts for much of the total car weight
reduction that occurred during the time
period, diminishing the danger to the
occupants of other cars.
Page 22
GAO/OCG-93-6TR Program Evaluation Issues
Some Promising Initiatives Do Exist
This year, in contrast to 1988, we identified a
number of agency evaluations that were well
done or work in progress that seems
promising.
Centers for
The Congress requested an independent
Disease Control
review of the investigation by the Centers for
Disease Control (CDC) into the causes of the
HIV infections found among patients of a
Florida dentist. We concluded that CDC'S
research-especially that on genetic
sequencing-was well done and our review
supports CDC'S conclusions that five patients
became infected as a result of receiving care
from the dentist with AIDS, although the
mode of transmission remains uncertain.
This review suggests that CDC made an
exemplary effort to find and use the best
information available at the time.
Agency for Health
We reported that despite considerable
Care Policy and
changes in the management of breast cancer
Research
treatment since the 1970s, there was no
observable improvement in survival. That we
were the only organization to examine
nationally how well cancer patients fared
underscored the fact that there was no
federal agency charged specifically to
examine health outcomes. That situation
Page 23
GAO/OCG-93-6TR Program Evaluation Issues
Some Promising Initiatives Do Exist
changed in 1989 with the establishment of
the Agency for Health Care Policy and
Research. Currently, this agency has within
its mandate the broad areas of determining
the effectiveness of medical interventions,
creating medical practice guidelines, and
disseminating information on outcomes.
This offers the promise of advances in the
quality and quantity of information that will
be available for making informed, future
health care policy decisions.
Office of
In response to concerns in the Congress and
Personnel
among such groups as the National
Management and
Commission on the Public Service that the
Merit Systems
quality of the federal professional and
Protection Board
technical workforce was declining in the
1980s, we examined the available data and
found no significant evaluation of workforce
quality either in the major agencies or in the
Office of Personnel Management (OPM).
However, in response to our 1988 report,
OPM and the Merit Systems Protection
Board have in the last 4 years developed
significant evaluation programs involving
measurements of quality among those
recruited and retained in a number of key
occupations, and an expanded effort is being
planned on the basis of a national advisory
panel's work.
Page 24
GAO/OCG-93-6TR Program Evaluation Issues
Related GAO Products
Importance of
Bigeye Bomb: Unresolved Developmental
Program
Issues (PEMD-89-27, Aug. 11, 1989).
Evaluation
Immigration Reform: Major Changes Likely
Under S.358 (PEMD-90-5, Nov. 9, 1989).
Medical Devices: FDA's Implementation of
the Medical Device Reporting Regulation
(PEMD-89-10, Feb. 17, 1989).
Program Evaluation Issues (OCG-89-8TR, Nov.
1988).
Program Effects
Vocational Rehabilitation Program: Client
Often Unknown
Characteristics, Services Received, and
Employment Outcomes (T-PEMD-92-3, Nov. 12,
1991).
Drug Abuse Prevention: Federal Efforts to
Identify Exemplary Programs Need Stronger
Design (PEMD-91-15, Aug. 22, 1991).
Military Training: Its Effectiveness for
Technical Specialties Is Unknown (PEMD-91-4,
Oct. 16, 1990).
Foster Care: Incomplete Implementation of
the Reforms and Unknown Effectiveness
(PEMD-89-17, Aug. 14, 1989).
Page 25
GAO/OCG-93-6TR Program Evaluation Issues
Related GAO Products
Program
Higher Education: Gaps in Parents' and
Targeting Often
Students' Knowledge of School Costs and
Unknown
Federal Aid (PEMD-90-20BR, July 31, 1990).
Food Stamp Program: A Demographic
Analysis of Participation and
Nonparticipation (PEMD-90-8, Jan. 19, 1990).
Cancer Treatment: National Cancer
Institute's Role in Encouraging the Use of
Breakthroughs (PEMD-89-4BR, Oct. 20, 1988).
Failure to Use
Summary of the Strategic Nuclear Triad
Quality Studies
Evaluation (PEMD-92-36R, Sept. 28, 1992).
Reproductive and Developmental Toxicants:
Regulatory Actions Provide Uncertain
Protection (PEMD-92-3, Oct. 2, 1991).
Highway Safety: Have Automobile Weight
Reductions Increased Highway Fatalities?
(PEMD-92-1, Oct. 8, 1991).
USDA Commodity Forecasts: Inaccuracies
Found May Lead to Underestimates of
Budget Outlays (PEMD-91-24, Aug. 13, 1991).
Waste Minimization: EPA Data Are Severely
Flawed (PEMD-91-21, Aug. 5, 1991).
Page 26
GAO/OCG-93-6TR Program Evaluation Issues
Related GAO Products
Promising
AIDS: CDC'S Investigation of HIV Transmissions
Evaluation
by a Dentist (PEMD-92-31, Sept. 29, 1992).
Efforts
Federal Workforce: A Framework for
Studying Its Quality Over Time (PEMD-88-27,
Aug. 4, 1988).
Page 27
GAO/OCG-93-6TR Program Evaluation Issues
Transition Series
Economics
Budget Issues (GAO/OCG-93-1TR).
Investment (GAO/OCG-93-2TR).
Management
Government Management Issues
(GAO/OCG-93-3TR).
Financial Management Issues
(GAO/OCG-93-4TR).
Information Management and Technology
Issues (GAO/OCG-93-5TR).
Program Evaluation Issues (GAO/OCG-93-6TR).
The Public Service (GAO/OCG-93-7TR).
Program Areas
Health Care Reform (GAO/OCG-93-8TR).
National Security Issues (GAO/OCG-93-9TR).
Financial Services Industry Issues
(GAO/OCG-93-10TR).
International Trade Issues (GAO/OCG-93-11TR).
Commerce Issues (GAO/OCG-93-12TR).
Energy Issues (GAO/OCG-93-13TR).
Page 28
GAO/OCG-93-6TR Program Evaluation Issues
Transition Series
Transportation Issues (GAO/OCG-93-14TR).
Food and Agriculture Issues
(GAO/OCG-93-15TR).
Environmental Protection Issues
(GAO/OCG-93-16TR).
Natural Resources Management Issues
(GAO/OCG-93-17TR).
Education Issues (GAO/OCG-93-18TR).
Labor Issues (GAO/OCG-93-19TR).
Health and Human Services Issues
(GAO/OCG-93-20TR).
Veterans Affairs Issues (GAO/OCG-93-21TR).
Housing and Community Development
Issues (GAO/OCG-93-22TR).
Justice Issues (GAO/OCG-93-23TR).
Internal Revenue Service Issues
(GAO/OCG-93-24TR).
Foreign Economic Assistance Issues
(GAO/OCG-93-25TR).
Page 29
GAO/OCG-93-6TR Program Evaluation Issues
Transition Series
Foreign Affairs Issues (GAO/OCG-93-26TR).
NASA Issues (GAO/OCG-93-27TR).
General Services Issues (GAO/OCG-93-28TR).
Page 30
GAO/OCG-93-6TR Program Evaluation Issues
*U.S.G.P.0.:1993-336-740
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United States General Accounting Office
GAO
Transition Series
December 1992
The Public Service
UNITED STATES
GENERAL OFFICE
GAO/OCG-93-7TR
GAO
United States
General Accounting Office
Washington, D.C. 20548
Comptroller General
of the United States
December 1992
The Speaker of the House of Representatives
The Majority Leader of the Senate
In response to your request, this transition series report discusses a
topic that is critical to the successful implementation of the
government's programs-the need to acquire and retain a competent
and motivated federal workforce. The issues described in this report
include modernizing employment practices, enhancing federal
workforce management, fully implementing pay reform, and
rebuilding a positive public image for the public service to restore
public confidence in government and make it an attractive career
choice.
The GAO products upon which this report is based are listed at the
end of the report.
We are also sending this report to the President-elect, the Republican
leadership of the Congress, the appropriate congressional
committees, and the Director-designate of the Office of Personnel
Management.
Charlest Boweher
Charles A. Bowsher
Contents
Public Service
4
Issues
Modernizing
6
Employment
Practices
Enhancing
13
Federal
Workforce
Management
Fully
23
Implementing Pay
Reform
Rebuilding a
25
Positive Public
Image
Related GAO
28
Products
Transition Series
31
Page 2
GAO/OCG-93-7TR The Public Service
Page 3
GAO/OCG-93-7TR The Public Service
Public Service Issues
In our 1988 transition series, we reported
that the government was faced with a people
problem that impeded agencies in their
efforts to achieve their missions. We said
that the negative image of public
service-due largely to years of criticism of
federal employees and unethical conduct by
government officials-and the inadequacy of
federal compensation were significant
barriers to attracting and retaining a
high-quality workforce.
Important progress has been made in the
past 4 years. Criticism of federal employees
has subsided somewhat, major ethics reform
legislation has been enacted, and a new
pay-determining process has been put into
place to help narrow the ever-widening gap
between federal and private sector pay.
If the government is to be able to attract and
retain high-quality people, meet the public's
performance expectations, and regain a
positive public image, it is important not
only to sustain the initiatives begun during
the past 4 years but also to respond to other
emerging issues.
One such issue is reducing the size of
workforces. Federal managers do not always
have the flexibility, systems, or processes
Page 4
GAO/OCG-93-7TR The Public Service
Public Service Issues
they need to downsize effectively while both
meeting their mission requirements and
treating employees fairly.
Page 5
GAO/OCG-93-7TR The Public Service
Modernizing Employment Practices
Clearly, the federal government faces stiff
competition from other employers, who also
want the best and brightest. Competitive
dimensions (in addition to pay) include
recruiting and hiring processes, benefits
structures, and approaches to downsizing
when workforces must be reduced. Many
employers have more progressive
approaches in these areas than the federal
government.
Improving
The Office of Personnel Management (OPM)
Recruiting and
is improving many aspects of the
Hiring
government's recruiting and hiring
programs, but significant problems remain.
Federal recruitment efforts at the nation's
colleges and universities have been most
notable for their absence. Federal
employment information at colleges and
universities is often inadequate, and service
has sometimes been poor at OPM'S job
information centers. Information on federal
job openings is not always available or easy
to locate, and the application process
remains a mystery to many. OPM needs to
continue working with agencies to
strengthen federal recruiting efforts,
particularly at colleges and universities, and
to make information on federal employment
Page 6
GAO/OCG-93-7TR The Public Service
Modernizing Employment Practices
readily accessible nationwide. Closer
working relationships among OPM, federal
agencies, and college placement personnel
and increased involvement by agency
program managers in recruitment would also
help greatly.
Federal hiring mechanisms are burdensome
and complex. Many personnel officers and
program managers believe that the time it
takes to hire someone is a significant
problem. Rules have been designed to
ensure merit; increase the employment of
women, minorities, and veterans; and give
managers some flexibility. However, these
rules often do not meet their objectives;
sometimes they conflict and overwhelm both
managers and applicants.
The government needs a new hiring process,
but designing one will not be easy. Federal
agencies, the Congress, and other interested
parties must all work together to solve this
problem. We have ongoing efforts aimed at
identifying potential solutions.
Meeting the
Dramatic changes in the demographic
Changing Needs
composition of the nation's workforce are
of Our Workforce
presenting serious challenges to all
organizations in their efforts to be effective,
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GAO/OCG-93-7TR The Public Service
Modernizing Employment Practices
competitive employers. More and more
women are working, and the proportion of
families with both spouses in the labor force
has increased greatly. Furthermore, the
workforce is aging. The median age of the
workforce rose by more than 2 years from
34.3 in 1980 to 36.6 in 1990 and is predicted
to increase by another 4 years by 2005.
Progressive nonfederal employers are ahead
of the federal government in adapting to
changing times. For example, flexible
benefits are becoming increasingly available
in nonfederal organizations but are generally
not available to federal employees. Also,
unlike employees in many nonfederal
organizations, federal employees are
generally not permitted to use any portion of
accumulated sick leave to care for family
members who are ill unless they have a
contagious disease. Some companies have
begun programs to extend older employees'
careers and rehire retirees to fill temporary
needs. Other programs that appear to have
wide applicability, such as adoption
assistance or sick-child care, are available in
only a few agencies or for certain employees.
OPM has established a new office to
concentrate on work/family issues. This
office needs to monitor demographic
Page 8
GAO/OCG-93-7TR The Public Service
Modernizing Employment Practices
changes and develop and promote proposals
that will not only enable the government to
catch up with other employers but also
enable it to become a leader in the
work/family arena.
Equipping
Organizations often rely on attrition when
Agencies to
they need to reduce their workforces. When
Downsize the
the size of the reduction needed is relatively
Federal
small and sufficient time is available,
Workforce
attrition can work well for both the
employer and the employee. However, when
significant reductions are needed over
relatively short time frames, attrition alone
may not be enough.
Such is the situation facing the federal
government. The Department of Defense
(DOD) is in the process of reducing its
workforce by over 200,000 by fiscal year
1997 from its level in 1987. Given the federal
budget deficit, many civilian agencies could
face large reductions as well.
Federal workforce downsizing of the
magnitude expected will create a major
challenge to delivering quality programs and
services to the public. Federal approaches to
achieve voluntary reductions have met with
limited success. Both managers and
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GAO/OCG-93-7TR The Public Service
Modernizing Employment Practices
employees have criticized methods for
dealing with involuntary employee
separations as costly, unfair, and possibly
discriminatory.
What is the problem? Unfortunately, there
are many. The government has not created
sufficient incentives to induce voluntary
moves; the process for reductions in force
(RIF) is inflexible and has multiplier effects
on the number of persons affected; and job
placement programs are likely to be hard
pressed to place a high proportion of
registrants in jobs. Federal managers also
claim that the rigid rules for offering early
retirement and conducting RIFS often
frustrate their attempts to shape a workforce
needed to accomplish their agencies'
missions.
Recent legislation dealing primarily with DOD
downsizing provides new financial
incentives to encourage early retirements
and resignations; advance notice, expanded
job training, and placement assistance to
employees facing involuntary separations;
and various other forms of transition
assistance. It is important that these
additional tools be implemented to lessen
the financial and emotional effects on
displaced employees and minimize adverse
Page 10
GAO/OCG-93-7TR The Public Service
Modernizing Employment Practices
organizational impacts. Civilian agencies
also need to be given appropriate tools to
deal with downsizing, and all downsizing
approaches need to be evaluated to see if
they are equitable and do not adversely
affect mission accomplishment.
More specifically, the new administration
and the Congress will have to address
several questions.
Are additional incentives needed to induce
separations among those persons already
eligible for early retirement?
Will the implementation of voluntary
separation incentives recently authorized for
DOD effectively increase attrition without
being discriminatory while allowing
managers the flexibility to shape their
workforces to meet their needs?
Should voluntary separation incentives
recently authorized for DOD or other
incentives be provided to civilian agencies?
Will current job placement programs be able
to match sufficient numbers of displaced
employees with other government vacancies
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GAO/OCG-93-7TR The Public Service
Modernizing Employment Practices
without placing new restrictions on civilian
agency managers' discretion in hiring?
Are statutory and/or regulatory changes
needed to minimize the expected adverse
impact of involuntary separations on women
and minorities?
Page 12
GAO/OCG-93-7TR The Public Service
Enhancing Federal Workforce
Management
The public expects and has every right to
receive high-quality services at reasonable
costs from a government workforce that (1)
reflects the people it serves, (2) operates
efficiently and effectively, and (3) is held
accountable for results. Too often, limited
top-management attention or complex and
restrictive laws, regulations, and processes
have hampered the government's ability to
effectively manage its workforce toward
meeting these objectives.
Intensifying
The federal government has made strides
Efforts to
toward attaining a workforce that reflects
Diversify the
the nation's diverse population, but much
Federal
more needs to be accomplished. Although
Workforce
women and minorities comprise the majority
of the federal workforce at grades 2 through
11, their presence decreases to about
30 percent for grade 13 positions and
continues downward to about 17 percent for
the Senior Executive Service (SES).
Moreover, 1990 federal workforce data show
that one or more women or minority groups
were underrepresented in 97 percent of 261
key jobs-jobs that lead to middle- and
upper-level management positions.
Management commitment at all levels of
government and continued monitoring are
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GAO/OCG-93-7TR The Public Service
Enhancing Federal Workforce
Management
needed if the federal government is to
achieve a diverse workforce. Agencies
frequently do not set measurable affirmative
employment goals. At agencies we have
reviewed, SES performance workplans do not
specifically hold managers accountable for
meeting affirmative employment objectives.
Specificity is needed to truly gauge how
successfully the executives are carrying out
their affirmative employment
responsibilities. Furthermore, many agencies
have submitted late or incomplete program
plans to the Equal Employment Opportunity
Commission (EEOC). EEOC has often approved
these plans even though they lacked such
important elements as certain workforce
analyses needed to determine progress in
achieving a representative workforce.
EEOC must provide stronger leadership. It
must work with federal agencies to help
them better identify and address barriers to
the entry and progression of women and
minorities. We have made a number of
recommendations to EEOC for improving the
government's affirmative employment
program. These include the need for better
guidance to agencies on required workforce
analyses and the need for EEOC to withhold
approval of agency plans until substantive
requirements are met. EEOC has begun to
Page 14
GAO/OCG-93-7TR The Public Service
Enhancing Federal Workforce
Management
address our concerns. It needs to continue to
work with agencies to strengthen
accountability for results.
Although stronger leadership from EEOC is
essential, the President and the Congress
need to emphasize to agency heads that they
must have programs in place and hold their
senior managers accountable for achieving a
representative workforce, particularly at
higher grade levels.
Allowing
The government's performance management
Agencies to
system is commonly perceived as not
Manage
working well. Often, it does not meet its
Performance
objectives to improve and motivate
More Flexibly
employees' performance, achieve individual
accountability, and instill employees' trust in
the assessment process.
One reason is that the government's
performance management system has been
and continues to be too rigid. Consistent
with private sector trends, many federal
agencies are beginning to move away from
rigid, centralized, and individual-oriented
management approaches to the more
flexible, decentralized, team-oriented, and
customer-based approaches similar to those
embodied in the principles of total quality
Page 15
GAO/OCG-93-7TR The Public Service
Enhancing Federal Workforce
Management
management (TQM). The government needs
to continue moving toward a flexible
performance management system that
agencies can tailor to their own missions,
work environments, and workforces.
Another reason the system is not working
well is that the link between performance
and pay is considered by many to be too
weak to motivate, reward, or penalize
employees. For example, many employees
believe that the amount of money provided
through performance awards is not
sufficient to serve as a motivator, and
employees who continue to perform poorly
over a long period are often not penalized
through reductions in pay. Consistent with
the principles of TQM, some managers would
like to have greater ability to reward team
efforts.
In addition, as we noted in our 1988
transition series report on the Public
Service, the lack of measurable goals and
objectives makes it difficult to know
whether important programs and initiatives
are succeeding. Our more recent work
shows this to be a continuing problem. It is
difficult to hold organizations or people
accountable without clear results-oriented
Page 16
GAO/OCG-93-7TR The Public Service
Enhancing Federal Workforce
Management
goals and good performance measures to
gauge progress in achieving those goals.
Performance management is one of the most
difficult and complex issues in human
resource management. While there appears
to be a consensus on what the specific
problems are, there does not appear to be a
consensus on specific solutions. Thus, the
executive and legislative branches need to
work on an approach for (1) giving agencies
the flexibility they need to develop solutions
that will work for them, (2) linking
performance and pay in a manner that will
better motivate and reward employees, and
(3) establishing results-oriented goals and
better using performance measures to gauge
progress.
Improving Labor-
Labor-management relations experts as well
Management
as agency and union representatives across
Relations
the country agree that the federal
labor-management relations program is not
working well. They say that the program is
too adversarial and that it suffers from
excessive litigation over procedural and
minor matters. In addition, processes used to
resolve disputes are viewed as too slow and
complex.
Page 17
GAO/OCG-93-7TR The Public Service
Enhancing Federal Workforce
Management
Comprehensive reform is essential to the
effective conduct of the public's business,
including implementation of the quality
improvement initiatives that emphasize
employee involvement and teambuilding
being sought by federal agencies. Because
the perceived problems are systemic and
widespread, convening a panel of
participants in the federal program and
nationally recognized experts in labor
relations could be the best approach for
developing a viable reform proposal.
Reforming Health
The Federal Employee Health Benefits
Benefits
Program (FEHBP) is the largest
employer-sponsored health insurance
program in the United States. In fiscal year
1993, it will provide health benefits for about
9 million federal employees, annuitants, and
their dependants at an estimated cost of
$16 billion. Over the years, the Congress,
OPM, federal employees, and employee
unions have expressed concerns about
FEHBP'S structure and cost and have called
for reform.
The debate on FEHBP reform has
appropriately focused on issues related to
program design, availability of choice among
plans, and cost of health benefits. At the
Page 18
GAO/OCG-93-7TR The Public Service
Enhancing Federal Workforce
Management
Congress' request, others have examined and
reported on these issues, essentially
reinforcing the call for reform. Also at the
Congress' request, we have looked at the
program's administrative costs, almost all of
which are incurred by contractors.
At a cost of over one-half billion dollars
annually, contractors' administration of
FEHBP is an important consideration. We
believe that as much as $200 million annually
could be saved if FEHBP'S administrative
costs were reduced to the levels of other
large health benefits programs we reviewed.
However, to achieve savings of that
magnitude, it would be necessary to legislate
a more uniform benefits structure and allow
for the procurement of administrative
services under competitive, fixed-price
contracts that would periodically be rebid.
Currently, benefits vary widely among plans,
and OPM uses essentially noncompetitive,
self-renewing contracts with carriers.
The new Congress and administration need
to continue the debate on FEHBP and reach
consensus on reform, including the potential
for saving up to $200 million annually in
administrative costs. In the meantime, OPM
could save up to $35 million yearly by better
managing administrative costs under the
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GAO/OCG-93-7TR The Public Service
Enhancing Federal Workforce
Management
current FEHBP structure. We believe that
more thorough OPM analyses and
comparisons of operational costs among
plans could identify opportunities for cost
savings.
OPM has been responsive to our
recommendations but has been hampered by
limited staffing in its efforts to better oversee
program administrative costs as well as
combat fraud and abuse in the program. The
Congress and the administration need to
work with OPM to ensure that reasonable
staffing levels are available.
Choosing
In today's environment of tight budgets,
Between
agencies face tough challenges
Employees and
accomplishing their missions. A key issue is
Contractors
whether to use contractors or expand the
workforce. This issue has two major
components. One relates to the flexibility
agencies have to make these decisions. The
other relates to the core expertise agencies
need to oversee and control contractors.
Federal managers have not often had
sufficient flexibility to choose between
hiring employees or contractors because of
restrictive legislation or personnel ceilings
imposed by the Office of Management and
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GAO/OCG-93-7TR The Public Service
Enhancing Federal Workforce
Management
Budget (OMB) or the Congress. Agencies
frequently must use contractors even when
they believe it would be more appropriate to
use employees because of the nature of the
work involved or because it would be less
costly to use employees.
For example, legislative and budgetary
restrictions on the Environmental Protection
Agency's (EPA) Superfund Program
necessitated the use of contractors rather
than employees. According to EPA officials, it
is easier to get OMB'S approval for contract
dollars than for employee positions for
various agency programs. Also, personnel
ceilings imposed by OMB were a major factor
inhibiting the Department of Energy (DOE)
from achieving substantial savings by having
government employees rather than
contractors perform support service
functions.
Another problem sometimes faced by
agencies, due at least in part to restrictions
on hiring employees, is the lack of sufficient
staff capability to oversee and control
contractors. The lack of this capability has
contributed to serious problems in
government programs, such as safety
problems at nuclear weapons production
plants and in the nation's space program.
Page 21
GAO/OCG-93-7TR The Public Service
Enhancing Federal Workforce
Management
Although OMB has indicated that it is willing
to authorize additional employee positions,
the use of personnel ceilings as a control
device has left agencies with the perception
that OMB is still reluctant to do so. The
Congress and OMB need to provide agencies
with the authority and flexibility to use
government employees rather than
contractors when employees would be more
appropriate, considering the nature of the
work involved, or could more cost
effectively carry out agencies' missions.
Page 22
GAO/OCG-93-7TR The Public Service
Fully Implementing Pay Reform
Four years ago, it was generally recognized
that inadequate salaries were a primary
cause of the government's recruitment and
retention problems. In 1990, the Bush
administration and the Congress reached
agreement on a comprehensive, long-term
pay reform program designed to ultimately
make federal salaries competitive with the
private sector. The program was enacted
into law and has been favorably received.
The basis for this legislation was well
founded, namely, that high-quality people
needed to effectively run government
programs were finding employment
elsewhere.
But budgetary constraints could jeopardize
full implementation of pay reform. Achieving
a consensus between the administration and
the Congress was a long, arduous process
that would be difficult to reestablish if the
current program were to become
sidetracked. Full implementation of pay
reform is a key building block of a more
effective government and important to the
government's ability to attract and retain a
highly qualified and motivated workforce. If
the size of the workforce, coupled with
budget deficits, makes pay reform too
difficult to fund, the Congress and the
administration may want to consider the
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GAO/OCG-93-7TR The Public Service
Fully Implementing Pay Reform
option of reducing the size of the workforce
to allow full implementation of pay reform.
Page 24
GAO/OCG-93-7TR The Public Service
Rebuilding a Positive Public Image
Public respect for and confidence in
government have been diminishing. News
reports of alleged misconduct by
government officials or efforts by former
federal officials to influence decision-making
have not helped project a positive image of
government.
In 1989, the Congress and President Bush
forged a consensus on ethics reform in the
federal government and enacted the Ethics
Reform Act of 1989. The act strengthened
federal conflict-of-interest statutes and
employee financial disclosure requirements,
with a view toward achieving greater
uniformity in ethics rules among all three
branches of the government. All three
branches have also been given additional
authority and responsibility to ensure
effective program implementation.
Federal agencies in the executive branch
have varied in the intensity and effectiveness
of their efforts to prevent, detect, and deal
with conflicts of interest between
employees' official duties and their private
interests. The effectiveness of the ethics
program has been impeded by insufficient
top-management emphasis on implementing
effective employee financial disclosure
reporting and inadequate review of
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GAO/OCG-93-7TR The Public Service
Rebuilding a Positive Public Image
employees' activities outside the
government.
Agencies' efforts to address employees'
conflicts of interest have also been impeded
by shortages of staff assigned to review
disclosure reports and by the failure of some
agencies to require employees holding
positions vulnerable to conflicts of interest
to file disclosure reports (or to report
outside activities). Furthermore, the
executive branch's supervising ethics office,
the Office of Government Ethics (OGE), has
been hampered in its monitoring and
enforcement efforts by limited staff and
authority. Recent legislation authorized
more staff and enforcement powers.
Agency heads must aggressively pursue
strong ethics programs, including
requirements for producing effective
employee disclosure of financial and outside
interests and a sufficient number of properly
qualified staff assigned to review these
interests and ensure that they are
appropriate.
Problems with financial disclosure programs
also exist in the legislative and judicial
branches, SO they, too, need to continuously
improve their efforts.
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GAO/OCG-93-7TR The Public Service
Rebuilding a Positive Public Image
Another dimension of strong ethics
programs in the executive branch is the
willingness and ability of employees to
report misconduct without fear of retaliation
and with the understanding that their
allegations will be properly investigated.
Many federal employees do not have this
sense. In 1992, about 70 percent of the
employees we surveyed reported that they
had little or no knowledge about how the
whistleblower law protects them and said
that they did not know where to report
misconduct. One solution to this problem
would be to have agencies provide
information on where to report misconduct
during OGE-required ethics training
programs.
Page 27
GAO/OCG-93-7TR The Public Service
Related GAO Products
Modernizing
Federal Employment: How Federal
Employment
Employees View the Government as a Place
Practices
to Work (GAO/GGD-92-91, June 18, 1992).
Federal Employment: Displaced Federal
Workers Can Be Helped by Expanding
Existing Programs (GAO/GGD-92-86, May 5,
1992).
The Changing Workforce: Comparison of
Federal and Nonfederal Work/Family
Programs and Approaches (GAO/GGD-92-84,
Apr. 23, 1992).
The Changing Workforce: Demographic
Issues Facing the Federal Government
(GAO/GGD-92-38, Mar. 24, 1992).
Federal Recruiting and Hiring: Making
Government Jobs Attractive to Prospective
Employees (GAO/GGD-90-105, Aug 22, 1990).
Enhancing
Federal Health Benefits Program: Stronger
Federal
Controls Needed to Reduce Administrative
Workforce
Costs (GAO/GGD-92-37, Feb. 12, 1992).
Management
Government Contractors: Are Service
Contractors Performing Inherently
Governmental Functions? (GAO/GGD-92-11,
Nov. 18, 1991).
Page 28
GAO/OCG-93-7TR The Public Service
Related GAO Products
Federal Affirmative Employment: Status of
Women and Minority Representation in the
Federal Workforce (GAO/T-GGD-92-2, Oct. 23,
1991).
Federal Labor Relations: A Program in Need
of Reform (GAO/GGD-91-101, July 30, 1991).
Federal Affirmative Action: Better EEOC
Guidance and Agency Analysis of
Underrepresentation Needed (GAO/GGD-91-86,
May 10, 1991).
Performance Management: How Well Is the
Government Dealing With Poor Performers?
(GAO/GGD-91-7, Oct. 2, 1990).
Fully
Federal Pay: Private Sector Salary
Implementing Pay
Differences by Locality (GAO/GGD-91-63FS,
Reform
Apr. 29, 1991).
Recruitment and Retention: Inadequate
Federal Pay Cited as Primary Problem by
Agency Officials (GAO/GGD-90-117, Sept. 11,
1990).
Rebuilding a
Whistleblower Protection: Determining
Positive Public
Whether Reprisal Occurred Remains
Image
Difficult (GAO/GGD-93-3, Oct. 27, 1992).
Page 29
GAO/OCG-93-7TR The Public Service
Related GAO Products
Employee Conduct Standards: Some Outside
Activities Present Conflict-of-Interest Issues
(GAO/GGD-92-34, Feb. 10, 1992).
The Public Service (GAO/OCG-89-2TR,
Nov. 1988).
Page 30
GAO/OCG-93-7TR The Public Service
Transition Series
Economics
Budget Issues (GAO/OCG-93-1TR).
Investment (GAO/OCG-93-2TR).
Management
Government Management Issues
(GAO/OCG-93-3TR).
Financial Management Issues
(GAO/OCG-93-4TR).
Information Management and Technology
Issues (GAO/OCG-93-5TR).
Program Evaluation Issues (GAO/OCG-93-6TR).
The Public Service (GAO/OCG-93-7TR).
Program Areas
Health Care Reform (GAO/OCG-93-8TR).
National Security Issues (GAO/OCG-93-9TR).
Financial Services Industry Issues
(GAO/OCG-93-10TR).
International Trade Issues (GAO/OCG-93-11TR).
Commerce Issues (GAO/OCG-93-12TR).
Energy Issues (GAO/OCG-93-13TR).
Page 31
GAO/OCG-93-7TR The Public Service
Transition Series
Transportation Issues (GAO/OCG-93-14TR).
Food and Agriculture Issues
(GAO/OCG-93-15TR).
Environmental Protection Issues
(GAO/OCG-93-16TR).
Natural Resources Management Issues
(GAO/OCG-93-17TR).
Education Issues (GAO/OCG-93-18TR).
Labor Issues (GAO/OCG-93-19TR).
Health and Human Services Issues
(GAO/OCG-93-20TR).
Veterans Affairs Issues (GAO/OCG-93-21TR).
Housing and Community Development
Issues (GAO/OCG-93-22TR).
Justice Issues (GAO/OCG-93-23TR).
Internal Revenue Service Issues
(GAO/OCG-93-24TR).
Foreign Economic Assistance Issues
(GAO/OCG-93-25TR).
Page 32
GAO/OCG-93-7TR The Public Service
Transition Series
Foreign Affairs Issues (GAO/OCG-93-26TR).
NASA Issues (GAO/OCG-93-27TR).
General Services Issues (GAO/OCG-93-28TR).
*U.S.G.P.0.:1993-336-740 Page 33
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United States General Accounting Office
GAO
Transition Series
December 1992
Health Care Reform
UNITED STATES
GENERAL ACCOUNTING OFFICE
GAO/OCG-93-8TR
GAO
United States
General Accounting Office
Washington, D.C. 20548
Comptroller General
of the United States
December 1992
The Speaker of the House of Representatives
The Majority Leader of the Senate
In response to your request, this transition series report discusses
major policy, management, and program issues facing the Congress
and the new administration in the area of health care reform. The
issues include (1) access to health insurance for the uninsured,
(2) private health insurance market reforms, (3) health care cost
containment, (4) administrative simplification, (5) fraud and abuse
controls, (6) diffusion and pricing of new medical technologies, and
(7) medical malpractice reform.
As part of our high-risk series on program areas vulnerable to waste,
fraud, abuse, and mismanagement, we are issuing a related report,
Medicare Claims (GAO/HR-93-6, Dec. 1992).
The GAO products upon which this transition series report is based
are listed at the end of this report.
We are also sending copies of this report to the President-elect, the
Republican leadership of the Congress, the appropriate congressional
committees, and the Secretary-designate of the Department of Health
and Human Services.
Charles A. Bowsher
Contents
Health Care
4
Reform
Access to Health
6
Insurance for the
Uninsured
Private Health
9
Insurance Market
Reforms
Health Care Cost
12
Containment
Administrative
19
Simplification
Fraud and Abuse
22
Controls
Diffusion and
24
Pricing of New
Medical
Technologies
Medical
26
Malpractice
Reform
Page 2
GAO/OCG-93-8TR Health Care Reform
Contents
Observations
28
About Health
Care Reform
Related GAO
29
Products
Transition Series
32
Page 3
GAO/OCG-93-8TR Health Care Reform
Health Care Reform
A key challenge facing the new Congress and
administration is finding a better way to
manage and finance the U.S. health care
system while preserving the high-quality,
innovative medical care the United States
has achieved. The United States is projected
to spend 18 percent of its gross domestic
product (GDP) on health care by the year
2000 -far more than any other
industrialized country. These growing costs
are being shared by individuals and the
business community as well as federal and
state programs. The inexorable rise in health
care costs is constraining wage increases
and the financial capability of federal and
state governments to address other pressing
social concerns. We have emphasized that
failure to control overall health care costs
will stymie efforts to control outlays on
Medicare and Medicaid-the fastest growing
major programs in the federal budget-and
will make it more difficult, if not impossible,
to bring the federal budget into balance. 1
Individuals, business, and the government
need to work together to tame the cost spiral
for health care.
Despite having the highest costs in the
industrialized world, our health care system
is not serving large portions of our
¹See particularly app. III in Budget Deficit: Appendixes on Outlook,
Implications, and Choices (GAO/OCG-90-5A, Sept. 28, 1990).
Page 4
GAO/OCG-93-8TR Health Care Reform
Health Care Reform
population very well. Nearly 34 million
Americans are uninsured and millions more
are underinsured or fear they might lose
coverage if they develop a serious medical
condition, lose their job, or change
employers.
The Congress has asked us to review
approaches developed in American
communities and foreign countries that
might help explain the root causes of our
health care problems and suggest possible
solutions. We have examined the
experiences of Canada, France, Germany,
and Japan as well as U.S. federal programs
and state and community initiatives. If the
United States is to broaden access and
contain health spending, there is a need to
consider adopting features common to
successful systems that we have observed in
other countries and within our own borders.
A reformed U.S. system must also build on
the strengths of the nation's current health
care system. A strong research
establishment, the continuing development
of technology, and the capacity to evolve
more efficient service delivery mechanisms
are among the strengths of the U.S. health
care system that should be preserved.
Page 5
GAO/OCG-93-8TR Health Care Reform
Access to Health Insurance for the
Uninsured
Universal access to health insurance is an
achievable goal. Countries like Canada,
France, and Germany provide high-quality
health care to all their citizens, yet spend a
considerably smaller share of their nations'
resources on health. Within our own
borders, Hawaii is the state with the largest
share of its population covered by health
insurance. Rochester, New York, counts
7.1 percent of its population under the age of
65 as uninsured compared with a national
average of about 15 percent. Yet both Hawaii
and Rochester have achieved enviable
records in terms of health cost containment
and the level of insurance premiums.
Universal access to health insurance is not
free. Estimates for providing the 34 million
persons who are uninsured with health
insurance range from $12 billion to
$27 billion annually. These costs are not the
only factor that has made it difficult to
achieve universal access to health insurance
in the United States. Universal access would
also entail major changes in the role of
government, the structure of the health
finance system, and the financial
responsibilities of individuals and
employers. An employer mandate would
compel businesses to provide or finance
insurance for their employees and may add
Page 6
GAO/OCG-93-8TR Health Care Reform
Access to Health Insurance for the
Uninsured
new costs and responsibilities for many
small firms. A Canadian-style system would
involve a substantial increase in the share of
health care costs financed through the tax
mechanism.
The United States is considering a
commitment to universal coverage not only
because of the needs of the 34 million
uninsured but also because such coverage
can contribute to both short- and long-term
strategies for cost containment. Universal
coverage contributes to lowering
administrative costs for providers by
relieving them of the burden of assessing
insurance status before treatment and by
limiting losses associated with bad debt.
Changes in these two areas would be
especially beneficial for institutions such as
teaching hospitals and public hospitals in
large cities that currently serve large
numbers of uninsured patients. Universal
coverage also contributes to system
efficiency by reducing the need for the
uninsured to use more expensive treatment
settings such as the hospital emergency
room because they are not covered for
treatment in less expensive settings.
Moreover, adequate coverage for preventive
and primary care for chronic conditions can
Page 7
GAO/OCG-93-8TR Health Care Reform
Access to Health Insurance for the
Uninsured
help avoid more costly and serious
treatments in the future.
Universal health insurance coverage is not
ensured in all of the comprehensive reform
proposals, although all proposals seek to
make significant inroads to reducing the
uninsured population. National health
insurance plans that cover all citizens
explicitly solve the problem of the
uninsured. Proposals that rely on the
existing employer-based insurance model
require development of complementary
programs to cover the uninsured who are
not employed and any employed persons or
family members who remain uninsured
under the employer-based plans.
For example, Hawaii's mandate that
employers provide insurance coverage does
not require that health insurance coverage
be provided to part-time workers or to
family members of insured workers. To
address these gaps in coverage and to
include the unemployed who are not eligible
for Medicaid, Hawaii developed a
supplemental state-sponsored insurance
plan to extend coverage to these groups. The
state estimates that it has reduced the
number of uninsured to about 2 percent of
its population.
Page 8
GAO/OCG-93-8TR Health Care Reform
Private Health Insurance Market
Reforms
About three-fourths of uninsured Americans
are workers or their dependents, and just
over one-half of uninsured workers are
employed by firms with fewer than 25
employees. Some underwriting and rating
practices in the private insurance industry
have made obtaining affordable health
insurance difficult or impossible under
several conditions: when an insured worker,
dependent family member, or coworker in
the same risk pool develops an expensive
medical condition; when a worker changes
jobs; or when a firm changes insurance
carriers. If comprehensive reform is based
on the current employer-based private
insurance system, reforms of insurance
practices that affect people in these
situations are essential.
Two broad types of health insurance reforms
would be needed-those designed to
improve availability and those designed to
improve affordability. Reforms related to
availability guarantee that insurance will be
available to all eligible members of employee
groups through
guaranteed issue of policies to all employer
groups and their eligible members,
Page 9
GAO/OCG-93-8TR Health Care Reform
Private Health Insurance Market
Reforms
guaranteed renewal of policies that eliminate
or restrict the capacity of insurers to cancel
policies because of medical history or to
introduce new policy exclusions at the time
of renewal, and
guaranteed continuity of coverage when
employers change insurers, employees
change jobs, or insurers become insolvent or
discontinue offering health insurance.
Because insurance may be available but still
priced out of the reach of small businesses,
affordability also needs to be addressed
through
restricting factors used in setting rates, such
as health status and previous claims
experience, and
limiting the range of premiums a single
insurer can charge for customers with
different risk characteristics.
These types of reforms are needed to ensure
that private insurance products are available
to everyone under employer-mandated
coverage plans. However, such reforms can
be a double-edged sword. While they would
increase availability and reduce insurance
premiums for higher-risk groups that have
Page 10
GAO/OCG-93-8TR Health Care Reform
Private Health Insurance Market
Reforms
been excluded from the market, the reforms
would generate higher premiums for those
currently insured in lower-risk groups who
would share in the costs of the extended
coverage.
The net effect of insurance market reforms
alone on reducing the ranks of the uninsured
is unclear. States have introduced a number
of these reforms in the last few years. Early
experience suggests that such reforms have
had a modest effect on reducing the ranks of
the uninsured when coupled with limited
subsidy programs and state assistance to
risk pooling.
Page 11
GAO/OCG-93-8TR Health Care Reform
Health Care Cost Containment
The call for control of health care costs is
now heard throughout U.S. society.
Expanding insurance coverage to the
uninsured would make cost control more
urgent, but even without that additional
spending, the upward sweep of health care
costs is threatening the financial position of
businesses, individuals, and governments.
Cost control entails some force that
disciplines the decisions of consumers and
providers. As a result, cost control means
that some segments of society will receive
less. Providers (such as physicians and
hospitals) will have lower revenues than if
present trends continue. Consumers may
face less choice among providers, and the
rate of improvement in medical technology
may slow.
Nonetheless, cost control is imperative.
Without it, the problem of the uninsured will
likely worsen as the unchecked rise in the
cost of insurance puts it out of the reach of
more and more people. Moreover, lack of
cost control will aggravate the budgetary
squeeze on the federal and state
governments. How to control costs with the
fewest adverse effects on the population is
the challenge.
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GAO/OCG-93-8TR Health Care Reform
Health Care Cost Containment
Among the many proposals for achieving
cost discipline in U.S. health care, two broad
strategies are currently most prominent:
managed competition and direct controls.
Both would use government regulation,
although in quite different ways. The two
strategies differ in the extent to which they
rely on market forces and in the extent to
which they have been tested in practice.
Managed competition would give regulation
a competition-enhancing slant by
establishing a complex set of rules within
which competition can occur. After
restructuring the marketplace, the
government would play umpire for insurers,
providers, and beneficiaries while letting
competition exert discipline and rein in
health care costs. The second strategy, direct
controls, would require public (or
quasi-public) authorities to set health care
prices, limit overall spending, and regulate
the spread of new technology.
The strategy of managed competition is
evolving, and its various proponents
sometimes define it in different ways.
Nonetheless, they agree on blending federal
regulation with incentives and private
initiative to create a cost-conscious
discipline for hospitals and physicians. Also,
current proposals assume heavy reliance on
Page 13
GAO/OCG-93-8TR Health Care Reform
Health Care Cost Containment
managed care health plans, such as health
maintenance organizations (HMO) and
preferred provider organizations (PPO), that
try to encourage efficiency by placing
providers at risk for health costs, using
administrative processes to attempt to
control services, or both.
In designing a practical system of managed
competition, two questions are pivotal:
First, can rates for health care plans be set
so that insurers are not rewarded for
"cream-skimming"?
Under current arrangements, a company
offering health insurance makes more
money by attracting people who are
healthier than average and by not insuring
bad health risks. Whether a system of
managed competition could prevent
cream-skimming-which would undermine
the system-is much debated. Our work on
Medicare's rate-setting for HMOS illustrates
the difficulty of the task.
Second, would managed competition
achieve cost savings at the expense of
quality?
Page 14
GAO/OCG-93-8TR Health Care Reform
Health Care Cost Containment
To prevent this, the proponents of managed
competition stress the need to create new
sources of information about the quality of
health care. How quickly such information
could be generated and how consumers
would use it are, however, open questions.
Our work on HMOS for Medicare enrollees
shows that quality assurance is needed to
avoid abuses due to cost-cutting.
The strategy of managed competition is
appealing to many. The Netherlands, for
example, is in the early stages of
implementing a particular version of the
strategy. But evaluating the likely
effectiveness of managed competition is
hampered by lack of a real test, abroad or
within an American state, in which a system
of managed competition could be observed.
Some research on states with relatively
strong competition among HMOS and other
managed care providers is mildly
encouraging. Nonetheless, these states have
not implemented managed competition, so it
is difficult to draw conclusions from them
about how much a managed competition
system would flatten the trend in costs.
The alternative approach, direct controls,
uses fee schedules and other price controls,
Page 15
GAO/OCG-93-8TR Health Care Reform
Health Care Cost Containment
spending targets and caps (sometimes called
"global budgets"), and controls on the
dispersal of new technology. Our analysis of
these controls also reveals both strengths
and weaknesses.
Direct controls have been employed in many
different settings and have been
implemented in a variety of ways. For
example, direct controls are used
systemwide in countries with many insurers
(such as Germany) and with a single insurer
(Canada). In the United States, direct
controls are used at the federal level
(Medicare uses a fee schedule and has
introduced a spending target for physicians'
services), at the state level (Maryland sets
hospital rates), and at the local level
(Rochester, New York, has used global
budgets for hospitals).
In addition, direct controls have, with
different degrees of success, restrained
health care costs. Our studies of American
and foreign health care provide evidence on
the effectiveness, in particular, of spending
controls and price controls. Thus, we found
that the cost containment strategy used in
Rochester, New York-which included
global budgets-seemed to have slowed the
rise in hospital costs. For France and
Page 16
GAO/OCG-93-8TR Health Care Reform
Health Care Cost Containment
Germany, our analysis showed that targets
and caps slowed the rate of spending
increases compared with what would have
happened without these policies. Our
analysis also confirmed that the strength of
enforcement is important: In Germany,
spending caps have replaced targets, which
were more weakly enforced, and the caps
have proved more effective in limiting
spending.
Direct controls on prices also have been
relatively effective in containing costs. As
our analysis showed, U.S. states that have
set rates for hospital services to which all
insurers in the state must adhere have
slowed the growth in their per capita health
spending. In addition, Medicare, which uses
a variant of price controls in reimbursing
hospitals, has slowed the rise in its costs for
hospital services. Other countries'
experience with price controls is generally
consistent with these findings for the United
States.
Direct controls are not a panacea, however.
Even viewed just in terms of cost
containment, they do not eliminate all
spending pressures. Moreover, direct
controls can hamper efficiency and retard
innovation. Budgeting procedures may not
Page 17
GAO/OCG-93-8TR Health Care Reform
Health Care Cost Containment
reward efficient providers and insurers and
may not penalize inefficient ones. Spending
caps and targets may freeze the prevailing
system of delivering health care and
discourage innovations like managed care.
Budgets may adapt too slowly to changes in
technology, the demographic mix of
patients, and methods of delivering care.
Price controls can slow or block a needed
shift of resources, say from one specialty to
another, when demand or supply conditions
change. To some extent these difficulties can
be mitigated, but still they must be weighed
when the choice of a spending control
strategy is made.
In sum, neither managed competition nor
direct controls is without drawbacks.
Indeed, some analysts and policymakers are
crafting proposals that combine the
market-oriented advantages of managed
competition with the extra cost discipline of
direct controls-specifically, a cap on
overall health spending. These hybrid plans
are too sketchy as yet for observers to
determine whether the two strategies can be
blended, or how effective such a hybrid
system might be.
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GAO/OCG-93-8TR Health Care Reform
Administrative Simplification
In the United States, nearly 6 percent of total
health expenditures in 1989 were accounted
for by the administration of government
health programs and private insurers. In
sharp contrast, Canada spends about
one-fifth as much proportionately on these
insurance overhead functions. In addition,
U.S. providers spend billions of dollars each
year for billing and other administrative
activities directly attributable to our system
of financing health care. Providers in
Canada, Germany, France, and Japan incur
lower costs, in part because they deal with a
more unified payment mechanism. While
considerable debate continues about the
precise magnitude of the potential savings in
administrative overhead and providers'
administrative burdens associated with
specific reform proposals, there is general
agreement that significant savings can be
achieved in this area.
Administrative expenses for private
insurance plans average about 12 percent,
but they can be as high as 40 percent of
claims costs for individual and small group
plans. When multiple insurers market a
range of plans differing in scope of coverage,
the result is significant overhead costs to
cover claims processing and marketing.
While a wide range of insurers and plans
Page 19
GAO/OCG-93-8TR Health Care Reform
Administrative Simplification
may create greater consumer choice and
greater responsiveness to consumers' needs,
this wide range is part of the reason for
higher administrative costs. Physicians,
hospitals, and other providers must expend
resources on billing and administrative
procedures to deal with the fragmented
payment system.
Almost all reform proposals attempt to
achieve cost savings by reducing
administrative costs through one or more of
the following approaches:
combining large numbers of employers into
large insurance-buying cooperatives to
achieve administrative economies,
defining a single or limited number of basic
insurance plans to reduce marketing costs
and the burden on providers,
developing standardized claims forms and
billing procedures for all insurance plans and
providers,
eliminating insurance underwriting activities,
eliminating deductibles and copayments to
eliminate the need for providers to issue bills,
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GAO/OCG-93-8TR Health Care Reform
Administrative Simplification
using more inclusive methods for
reimbursing providers, such as global
budgets, and
using a single payer with uniform payment
rules and procedures in each market area.
Canada, for example, achieves substantial
administrative savings through a
combination of a single payer with uniform
payment rules and elimination of all
deductibles and copayments. The United
States might achieve a similar level of
administrative savings if it adopted a
Canadian-type reform, but the savings could
be largely offset by the additional use of
services associated with the elimination of
deductibles and copayments. Alternatively,
the United States could retain deductibles,
copayments, and utilization review activities.
This approach would reduce potential
administrative savings but result in greater
control over potential costs associated with
increased use of health services. If the
United States should choose a system that
depends on employer-based private
insurance, some level of administrative
savings could still be achieved through a
combination of the other approaches
described above.
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GAO/OCG-93-8TR Health Care Reform
Fraud and Abuse Controls
The United States may want to invest more,
rather than less, in the administrative
resources required for detection of
fraudulent and abusive practices by health
care providers. Estimates vary widely on the
losses resulting from fraud and abuse, but
the most common is about 10 percent of
total health care spending or about $80
billion annually. Only a token amount of
administrative resources are devoted to
detection and elimination of fraudulent and
abusive practices.
Both public and private health insurance
programs are subject to fraud and abuse but
separately appear unable to combat it
successfully. Our work suggests that fraud
and abuse may be even more prevalent in
privately insured programs, in which control
efforts have not been as prominent and data
systems are more fragmented. Indeed,
federal health care programs have taken the
leadership role in prevention of such
practices. While a simpler and more uniform
payment and administrative system may
make it easier to detect potential fraud and
abuse, we believe that investing the needed
resources in designing the administrative
structure and continuing surveillance to limit
the potential for such practices is essential.
These issues are discussed more fully in our
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GAO/OCG-93-8TR Health Care Reform
Fraud and Abuse Controls
related report, Medicare Claims (GAO/HR-93-6,
Dec. 1992).
Page 23
GAO/OCG-93-8TR Health Care Reform
Diffusion and Pricing of New Medical
Technologies
The rapid spread and increased use of new
medical technologies has been relatively
unrestrained in recent years and has given
health spending added momentum.
Technological advances have sometimes led
hospitals to participate in a medical "arms
race," as they acquire expensive technology
and seek to keep patients and doctors from
shifting to rival hospitals.
Once declared eligible for reimbursement,
third-party payers-business, government,
and private insurers-have primarily
shouldered the financial burden of these
technological advances. However, insurers'
payment policies have not always
encouraged efficient and prudent use of
these medical services. Instead, insurers
have left themselves vulnerable to excessive
spending by giving providers incentives to be
wasteful or abusive in offering medical
services. In particular, our work has shown
that in some cases, insurers have not
adjusted payment rates to reflect the effect
of maturing technology on costs.
The challenge for policymakers is to find
ways to encourage development of new
technologies while ensuring their efficient
use. This can be accomplished through
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GAO/OCG-93-8TR Health Care Reform
Diffusion and Pricing of New Medical
Technologies
payment policies that reflect the costs
incurred by high-volume, efficient providers.
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GAO/OCG-93-8TR Health Care Reform
Medical Malpractice Reform
Savings in addition to those stemming from
comprehensive health care reform can be
achieved through fundamental changes in
the U.S. medical malpractice system. The
United States faces higher costs for medical
malpractice insurance and associated
defensive medicine costs than other nations.
U.S. medical malpractice premiums are
estimated to be only about 1 percent of total
U.S. health care costs. There is considerably
wider variation in estimates of the potential
additional costs of defensive
medicine-diagnostic tests and procedures
performed solely to protect physicians in the
event a malpractice claim is filed. The
American Medical Association estimated the
costs of defensive medicine at $20 billion in
1991. Moreover, physicians want relief, not
only from the financial burdens of
malpractice, but also from its emotional
burdens.
Cost reduction should not be the sole basis
for malpractice reform. Malpractice reform
also should be directed toward providing
better access to compensation for those who
are injured. Arbitration and no-fault
programs have been implemented in various
states as an alternative to a complex and
expensive court process. Many of these
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GAO/OCG-93-8TR Health Care Reform
Medical Malpractice Reform
programs also incorporate local practice
guidelines that, although not an absolute
defense, provide evidence in a judicial
process that accepted medical protocols
were followed. Furthermore, hospitals and
other medical settings are adopting
risk-management programs that are
expected to improve the quality of care. We
believe these efforts should continue to be
studied and, when positive effects are
demonstrated, should be considered in
conjunction with comprehensive health care
reform.
Page 27
GAO/OCG-93-8TR Health Care Reform
Observations About Health Care
Reform
Reform of U.S. financing of health insurance
and payment of health care providers is a
daunting task. U.S. health care is an $800
billion enterprise that is diverse,
complicated, and dynamic. Achieving reform
will be particularly difficult because, to
many people, reform seems to threaten a
good situation. People whose health
insurance is adequate and whose health care
is good may fear that reform will result in
diminished care or higher costs for them.
For providers as well as consumers, reform
of the health care marketplace will cause a
considerable reshuffling and generate losers
as well as winners.
Moreover, reform will not produce a
structure that is perfect. Our reviews of the
health systems of other countries shows that
after putting major reforms in place, these
countries continue to seek ways to improve
their systems. We believe that the
imperfections of any reform-and the
dynamic character of the health care
industry-make a stream of further changes
inevitable in the years ahead. However, there
may be greater risks in not undertaking
comprehensive health care reform. Without
reform, costs will continue to escalate while
a substantial number of Americans lack
access to health insurance.
Page 28
GAO/OCG-93-8TR Health Care Reform
Related GAO Products
Alternative
Health Care: Rochester's Community
Health Care
Approach Yields Better Access, Lower Costs
Systems
(GAO/HRD-93-44, forthcoming).
Access to Health Care: States Respond to
Growing Crisis (GAO/HRD-92-70, June 16, 1992).
Health Care Spending Control: The
Experience of France, Germany, and Japan
(GAO/HRD-92-9, Nov. 15, 1991).
Canadian Health Insurance: Lessons for the
United States (GAO/HRD-91-90, June 4, 1991).
Health Care Costs
Hospital Costs: Adoption of Technologies
Drives Cost Growth (GAO/HRD-92-120, Sept. 9,
1992).
Medicare: Excessive Payments Support the
Proliferation of Costly Technology
(GAO/HRD-92-59, May 27, 1992).
Health Care Spending: Nonpolicy Factors
Account for Most State Differences
(GAO/HRD-92-36, Feb. 13, 1992).
U.S. Health Care Spending: Trends,
Contributing Factors, and Proposals for
Reform (GAO/HRD-91-102, June 10, 1991).
Page 29
GAO/OCG-93-8TR Health Care Reform
Related GAO Products
Health Insurance
Employer-Based Health Insurance: High
Costs, Wide Variation Threaten System
(GAO/HRD-92-125, Sept. 22, 1992).
Access to Health Insurance: State Efforts to
Assist Small Businesses (GAO/HRD-92-90,
May 14, 1992).
Private Health Insurance: Problems Caused
by a Segmented Market (GAO/HRD-91-114,
July 2, 1991).
Fraud and Abuse
Medicare Claims (GAO/HR-93-6, Dec. 1992).
Medicare: One Scheme Illustrates
Vulnerabilities to Fraud (GAO/HRD-92-76,
Aug. 26, 1992).
Health Insurance: More Resources Needed
to Combat Fraud and Abuse (GAO/T-HRD-92-49,
July 28, 1992).
Health Insurance: Vulnerable Payers Lose
Billions to Fraud and Abuse (GAO/HRD-92-69,
May 7, 1992).
Medicare: Further Changes Needed to
Reduce Program and Beneficiary Costs
(GAO/HRD-91-67, May 15, 1991).
Page 30
GAO/OCG-93-8TR Health Care Reform
Related GAO Products
Medical
Medical Malpractice: Alternatives to
Malpractice
Litigation (GAO/HRD-92-28, Jan. 10, 1992).
Page 31
GAO/OCG-93-8TR Health Care Reform
Transition Series
Economics
Budget Issues (GAO/OCG-93-1TR).
Investment (GAO/OCG-93-2TR).
Management
Government Management Issues
(GAO/OCG-93-3TR).
Financial Management Issues
(GAO/OCG-93-4TR).
Information Management and Technology
Issues (GAO/OCG-93-5TR).
Program Evaluation Issues (GAO/OCG-93-6TR).
The Public Service (GAO/OCG-93-7TR).
Program Areas
Health Care Reform (GAO/OCG-93-8TR).
National Security Issues (GAO/OCG-93-9TR).
Financial Services Industry Issues
(GAO/OCG-93-10TR).
International Trade Issues (GAO/OCG-93-11TR).
Commerce Issues (GAO/OCG-93-12TR).
Energy Issues (GAO/OCG-93-13TR).
Page 32
GAO/OCG-93-8TR Health Care Reform
Transition Series
Transportation Issues (GAO/OCG-93-14TR).
Food and Agriculture Issues
(GAO/OCG-93-15TR).
Environmental Protection Issues
(GAO/OCG-93-16TR).
Natural Resources Management Issues
(GAO/OCG-93-17TR).
Education Issues (GAO/OCG-93-18TR).
Labor Issues (GAO/OCG-93-19TR).
Health and Human Services Issues
(GAO/OCG-93-20TR).
Veterans Affairs Issues (GAO/OCG-93-21TR).
Housing and Community Development
Issues (GAO/OCG-93-22TR).
Justice Issues (GAO/OCG-93-23TR).
Internal Revenue Service Issues
(GAO/OCG-93-24TR).
Foreign Economic Assistance Issues
(GAO/OCG-93-25TR).
Page 33
GAO/OCG-93-8TR Health Care Reform
Transition Series
Foreign Affairs Issues (GAO/OCG-93-26TR).
NASA Issues (GAO/OCG-93-27TR).
General Services Issues (GAO/OCG-93-28TR).
Page 34
GAO/OCG-93-8TR Health Care Reform
*U.S.G.P.0.:1993-336-740
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