1 

GAO 

wvrrclo 

United States General Accounting Office 

Report to the Chairman, Special 

Committee on Aging, U.S. Senate 

ex 1987 AGING 

GAO Activities in 

Fiscal Year 1987 

lllllllllll 

134776 

GAO/R/RD-88-42 

GAO United States 

General Accounting Office 

Washington, DC. 20548 

Human Resources Division 

B-217196 

December 16, 1987 

1~~ The Honorable John Melcher 

u Chairman, Special Committee 

on Aging 

United States Senate 

Dear Mr. Chairman: 

This report is in response to your September 14, 1987, request for a 

compilation of our fiscal year 1987 activities regarding older Americans. 

Appendix I lists 64 issued products-37 reports, 14 briefing reports 

(nw), and 3 fact sheets (FS). Reports and briefing reports may include 

conclusions and recommendations, while fact sheets contain only information and limited analyses, Appendix II lists 65 assignments that we 

had in process as of September 30, 1987. 

In appendix III, we present our employment policies, which prohibit age 

discrimination. On September 30, 1987,44.9 percent of our work force 

was 40 years of age or older. We continue to provide individual retirement counseling and group preretirement seminars. 

As arranged with your office, we are sending copies of this report to 

interested congressional committees and subcommittees. Copies will also 

be made available to others on request. 

Sincerely yours, 

Richard L. Fogel 

Assistant Comptroller General 

Page 1 GAO/HRD-8842 GAO Aging Activities in Fhcal Year 1987 
Contents 

Getter 1 

’ ppendix 

iit 

I 

A0 Reports Relating 

t Issues Affecting the 

lderly Issued From 

if 

ctober 1, 1986, 

hrough September 

3b, 1987 

Medigap Insurance: Law Has Increased Protection 

Against Substandard and Overpriced Policies (GAO/ 

HRD-87-8, Oct. 17, 1986) 

Medicaid: Results of Certified Fraud Control Units (GAO/ 

HRD-87-12FS, Oct. 21, 1986) 

Pensions: Plans With Unfunded Benefits (GAO/HRD-87- 

15BR, Oct. 22, 1986) 

Social Security: Adjusting Continuing Disability Review 

Priorities (GAO/HRD-87-4, Oct. 22, 1986) 

Pension Plans: Government Data on Terminations With 

Excess Assets Should Be Improved (GAO/HRD-87-19, 

Nov. 12,1986) 

Health Facilities: New York State’s Oversight of Nursing 

Homes and Hospitals (GAO/HRD-87-24, Nov. 28, 

1986) 

Medicare: Need to Strengthen Home Health Care Payment 

Controls and Address Unmet Needs (GAO/HRD-87-9, 

Dec. 2, 1986) 

Social Security Disability: Implementation of the Medical 

Improvement Review Standard (GAO/HRD-87-3BR, 

Dec. 16,1986) 

Medical Malpractice: Six State Case Studies Show Claims 

and Insurance Costs Still Rise Despite Reforms (GAO/ 

HRD-87-21, Dec. 31, 1986) 

Medical Malpractice: Case Study on Arkansas (GAO/HRD87-218-1, Dec. 31, 1986) 

Medical Malpractice: Case Study on California (GAO/ 

HRD-87-21S-2, Dec. 31, 1986) 

Medical Malpractice: Case Study on Florida (GAO/HRD87-218-3, Dec. 31, 1986) 

Medical Malpractice: Case Study on Indiana (GAO/HRD87-218-4, Dec. 31, 1986) 

Medical Malpractice: Case Study on New York (GAO/ 

HRD-87-21S-5, Dec. 31, 1986) 

Medical Malpractice: Case Study on North Carolina (GAO/ 

HRD-87-2lS-6, Dec. 31, 1986) 

Posthospital Care: Discharge Planners Report Increasing 

Difficulty in Placing Medicare Patients (GAO/PEMD87-5BR, Jan. 23, 1987) 

6 

6 

9 

9 

10 

10 

11 

11 ’ 

12 

12 

13 

14 

14 

Page 2 GAO/HRG-M-42 GAO Aging Activities in Fiscal Year 1987 
-- 

Contents 

Mental Health Care: Licensing and Certification 

Requirements for Staff in State Hospitals (GAO/HRD87-38FS, Jan. 29, 1987) 

Medicare: More Hospital Costs Should Be Paid by Other 

Insurers (GAO/HRD-87-43, Jan. ‘29, 1987) 

Social Security: Demonstration Projects Concerning 

Interviews With Disability Claimants (GAO/HRD-87- 

35, Feb. 19, 1987) 

Health Facilities: Problems at Harlem Hospital in 

Complying With Medicare Standards (GAO/HRD-87- 

58, Feb. 20,1987) 

Budget Reduction: Effect of 1986 Sequestration on 

National Institute on Aging (GAO/HRD-87-54BR, 

Mar. 6, 1987) 

Medicaid: Lessons Learned From Arizona’s Prepaid 

Program (GAO/HRD-87-14, Mar. 6, 1987) 

Insurance Reserves: Strategies for Regulating the Federal 

Employees Health Benefits Program (GAO/HRD-87- 

10, Mar. 6, 1987) 

Social Security: Staff Reductions and Service Quality 

(GAO/HRD-87-66, Mar. 10, 1987) 

Social Security Administration: Stable Leadership and 

Better Management Needed to Improve Effectiveness 

(GAO/HRD-87-39, Mar. 18, 1987) 

Pension Plans: Government Insurance Program 

Threatened by Its Growing Deficit (GAO/HRD-87-42, 

Mar. 19, 1987) 

Medicare and Medicaid: Effects of Recent Legislation on 

Program and Beneficiary Costs (GAO/HRD-87-53, 

Apr. 8,1987) 

Medicaid: Addressing the Needs of Mentally Retarded 

Nursing Home Residents (GAO/HRD-87-77, Apr. 15, 

1987) 

Medical Malpractice: Characteristics of Claims Closed in 

1984 (GAO/HRD-87-55, Apr. 22,1987) 

Medicaid: Determining Cost-Effectiveness of Home and 

Community-Based Services (GAO/HRD-87-61, Apr. 

28, 1987) 

Health Care: Patient Transfers From Emergency Rooms to 

D.C. General Hospital (GAO/HRD-87-31, Apr. 30, 

1987) 

Medicaid: Interstate Variations in Benefits and 

Expenditures (GAO/HRD-87-67BR, May 4,1987) 

14 

15 

15 

15 

16 

16 

17 

17 

18 

18 

19 

19 I, 

19 

20 

20 

21 

Page 3 GAO/IUD-88-42 GAO Aging Activities in Fiscal Year 1987 
, 

Contents 

Medical Malpractice: A Framework for Action (GAO/ 

HRD-87-73, May 20, 1987) 

Long-Term Care Insurance: Coverage Varies Widely in a 

Developing Market (GAO/HRD-87-80, May 29, 1987) 

Social Security: Staff Reductions and Service Quality 

(GAO/HRD-87-97BR, June 2,1987) 

VA Health Care: Financial and Quality Control Changes 

Needed in Domiciliary Care (GAO/HRD-87-57, June 

18, 1987) 

Medicare: Comparison of Catastrophic Health Insurance 

Proposals (GAO/HRD-87-92BR, June 19, 1987) 

Medicare: Rehabilitation Service Claims Paid Without 

Adequate Information (GAO/HRD-87-91, July 9, 

1987) 

Medicare: Preliminary Strategies for Assessing Quality of 

Care (GAO/PEMD-87-15BR, July 10, 1987) 

Veterans Administration: VA Pensions to Medicaid 

Nursing Home Residents Should Be Reduced (GAO/ 

HRD-87-111, July 10, 1987) 

Social Security: Clients Still Rate Quality of Service High 

(GAO/HRD-87-103BR, July 14, 1987) 

Block Grants: Proposed Formulas for Substance Abuse, 

Mental Health Provide More Equity (GAO/HRD-87- 

109BR, July 16,1987) 

Medicare: Prescription Drug Issues (GAO/PEMD-87-20, 

July 16, 1987) 

Medicare: Payments to Radiologists, Anesthesiologists, 

and Pathologists (GAO/HRD-87-114BR, July 20, 

1987) 

Medicare and Medicaid: Stronger Enforcement of Nursing 

Home Requirements Needed (GAO/HRD-87-113, July 

22,1987) 

Medicare: Catastrophic Illness Insurance (GAO/PEMD-87- 

21BR, July 31,1987) 

Pension Plans: Many Workers Don’t Know When They 

Can Retire (GAO/HRD-87-94BR, Aug. 12, 1987) 

Protecting the Elderly: Federal Agencies’ Role Concerning 

Questionable Marketing Practices (GAO/HRD-87- 

120FS, Aug. 26,1987) 

Medicaid: Improvements Needed in Programs to Prevent 

Abuse (GAO/HRD-87-75, Sept. 1, 1987) 

Social Security: Telephone Accessibility (GAO/HRD-87- 

138, Sept. 16,1987) 

21 

22 

23 

23 

24 

24 

25 

25 

26 

26 

27 

27 

27 b 

28 

29 

29 

29 

30 

Page 4 GAO/HRDS8-42 GAO Aging Activities in Fiscal Year 1987 
Social Security: Staff Reductions &d Service Quality 

(GAO/HRD-87”139BR, Sept. 17, 1987) 

Social Security: More Must Be Done to Credit Earnings to 

Individuals’ Accounts (GAO/HRD-87-52, Sept. 18, 

1987) 

30 

31 

Veterans’ Benefits: Improving the Integrity of VA’s 

Unemployability Compensation Program (GAOIHRD87-62, Sept. 21, 1987) 

31 

Medicare: Legislative Amendment Would Avoid Adverse 32 

Effects on Disabled Beneficiaries (GAO/HRD-87-136, 

Sept. 28, 1987) 

Appehdix II 

GAO budits in Process 

33 

Appendix III 

GAO Activities 

Affecting Older 

Persons 

37 

Abbreviations 

HH briefing report 

cm continuing disability review 

DDS Disability Determination Service 

FEI 1131’ Federal Employees Health Benefits Program 

I% fact sheet 

GAO General Accounting Office 

I ICYA Health Care Financing Administration ~ 

IIIIS Department of Health and Human Services ~ 

1124s Internal Revenue Service 

NIA National Institute on Aging 

CPM Office of Personnel Management 

PBGC Pension Benefit Guaranty Corporation 

SSA Social Security Administration 

VA Veterans Administration 

Page 6 GAO/HRD-W-42 GAO Aging Activities in F’iscal Year 1987 
Abpendix I 

GAO Reports Relating to Issues Affecting the - 

Elderly Issued F’rom October 1,1986, Through 

September 30,1987 

Following are brief descriptions of the GAO reports relating to the elderly 

issued during fiscal year 1987. An asterisk after the report title indicates that the review was performed at the request of Committees or 

Members of Congress. 

edigap Insurance: 

Has Increased 

Medicare pays much of the health care costs of the elderly, but beneficiaries are responsible for paying deductibles and coinsurance. Almost 

from the beginning of Medicare, private insurers have offered insurance 

contracts, called Medigap policies, that supplement Medicare benefits. In 

1980 the Congress amended the Social Security Act to establish standards for Medigap insurance policies. To be certified by the Secretary of 

Health and Human Services, such policies must provide at least a minimum level of benefit coverage and include certain provisions and set 

minimum expected levels of benefit payouts, called loss ratios. 

GAO found that Medigap policies sold by commercial insurers with more 

than $50 million in premiums and Blue Cross/Blue Shield plans generally met the loss ratio requirements. However, over 60 percent of the 

commercial insurance policies with premiums under $50 million in 1984 

did not meet those requirements. 

GAO reported that differences in benefit coverage and loss ratios among 

policies illustrate the importance of comparison shopping; to assist the 

elderly, the federal and state governments have made available information useful in shopping for Medigap insurance. Although abuses still 

occur in the sale of Medigap policies, many states have attempted to 

prevent abuse through such actions as monitoring sales and advertising 

practices, revoking or suspending insurance agent licenses, and issuing 

cease and desist orders to insurers. 

Mkdicaid: Results of 

Cktified Fraud 

Chntrol Units (GAO/ 

HRD-87-lZFS, Oct. 21, ’ 

1986y+ . 

Y 

. 

This fact sheet includes information on the 36 states that had Medicaid 

fraud control units as of September 30, 1985. It presents the results of 

GAO'S efforts to determine, for states with certified fraud control units, 

their expenditures, including the federal and state governments’ share 

of the expenses, for fiscal years 1984-85; 

their results, including the number of convictions obtained, fines 

imposed, restitution ordered, and overpayments identified for calendar 

years 1984-85 and their deterrent effect; and 

changes that could strengthen their fraud control efforts. 

Page 6 GAO/HRD-89-42 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reporb Relating to Isrues Affecting the 

Elderly Issued Prom October 1,1986, Through 

bktptember 90,1987 

GAO obtained information from two major sources: (1) quarterly statistical data submitted by the fraud units to the Department of Health and 

Human Services’ (1~) Office of the Inspector General and (2) a questionnaire sent to the 36 certified units in operation during fiscal year 

1985. 

I 

Pensibns: Plans With The vested benefits of about 30 million people participating in about 

Unfulhded Benefits 110,000 pension plans are guaranteed, within certain limits, by a gov- 

(GAOI/HRD-87-15BR, 

ernment insurance program. The program, established in 1974 by the 

Oct. 42, 1986) 

Employee Retirement Income Security Act, is administered by the Pension Benefit Guaranty Corporation (PHCC). When a plan terminates with 

insufficient assets to pay guaranteed benefits, EWGC becomes plan trustee 

/ and assumes responsibility for paying the benefits. Claims from 

/ 

I 

underfunded plans that are terminated are financed from annual premiurns paid to the program by ongoing plans. 

Between the act’s enactment and the end of fiscal year 1985, about 

1,100 plans terminated with claims against the program because they 

were underfunded. Claims, which have been especially large in recent 

years, have exceeded income, causing the insurance program to operate 

at a deficit-estimated at $1.3 billion as of September 30, 1985. 

C~AO’analysis S of the extent of vested benefit underfunding in 1983 covered 14,681 of the universe of about 22,000 large defined ‘benefit plans 

(those with 100 or more participants). 

GAO concluded that the contingent liability to PBGC’S insurance program 

is significant and growing. Considering the insurance fund’s current deficit, GAO believes that the program could be in jeopardy if ithe recent 

trend in the termination of plans with large amounts of unfunded benefits continues. 

, 

Social Security: GAO reviewed the Social Security Administration’s (SSA'S) ,plans for 

Adjusting Continuing resuming continuing disability reviews (CDRS) involving &A'S implementation of the medical improvement review standard. GAO was concerned 

Disability Review that the limited CDH resources of the states’ Disability Determination 

Priorities (GAO/HRD- Services (DDSS) were not concentrated on the CDR cases th,at (1) would 

87-4, Oct. 22, i986) 

produce the most savings to the trust fund because medical improvement is highly possible and (2) involve claimants who have had actions 

pending on their cases for some time. 

Page 7 GAO/HRD-8842 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 30,1987 

GAO obtained information from two major sources: (1) quarterly statistical data submitted by the fraud units to the Department of Health and 

Human Services’ (HHS) Office of the Inspector General and (2) a questionnaire sent to the 36 certified units in operation during fiscal year 

1985. 

Pens 

UnfL 

(GA( 

Oct. : 

i 

1 

i 

6 L 

Ins: Plans With 

ided Benefits 

‘HRD-87-15BR, 

2,1986) 

The vested benefits of about 30 million people participating in about 

110,000 pension plans are guaranteed, within certain limits, by a government insurance program. The program, established in 1974 by the 

Employee Retirement Income Security Act, is administered by the Pension Benefit Guaranty Corporation (PBGC). When a plan terminates with 

insufficient assets to pay guaranteed benefits, PBGC becomes plan trustee 

and assumes responsibility for paying the benefits. Claims from 

underfunded plans that are terminated are financed from annual premiums paid to the program by ongoing plans. 

Between the act’s enactment and the end of fiscal year 1985, about 

1,100 plans terminated with claims against the program because they 

were underfunded. Claims, which have been especially large in recent 

years, have exceeded income, causing the insurance program to operate 

at a deficit-estimated at $1.3 billion as of September 30, 1985. 

GAO'S analysis of the extent of vested benefit underfunding in 1983 covered 14,581 of the universe of about 22,000 large defined benefit plans 

(those with 100 or more participants). 

GAO concluded that the contingent liability to PBGC'S insurance program 

is significant and growing. Considering the insurance fund’s current deficit, GAO believes that the program could be in jeopardy if the recent 

trend in the termination of plans with large amounts of unfunded benefits continues. 

Socitil Security: GAO reviewed the Social Security Administration’s (SSA’S) plans for 

Adjubting Continuing resuming continuing disability reviews (CDRS) involving SA'S implementation of the medical improvement review standard. GAO was concerned 

Disability Review that the limited CDR resources of the states’ Disability Determination 

Priotiities (GAO/HRD- Services (DDSS) were not concentrated on the CDR cases that (1) would 

87-4,, Oct. 22, 1986) 

produce the most savings to the trust fund because medical improvement is highly possible and (2) involve claimants who have had actions 

pending on their cases for some time. 

Page 7 GAO/HRD-88-42 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Repwt~~ IMatiny to Issuesi Affecting the 

Elderly Issued From October 1,1986, Through 

September 80,1987 

monthly report on terminations with excess assets, categorizes a termination as a spinoff when a plan is separated into two plans and one is 

terminated, irrespective of how working participants’ pension coverage 

is affected 

GAO concluded that to decide if changes should be made to mitigate the 

potential adverse effects of terminations with excess assets on participants’ pension coverage, policymakers need data showing the types of 

continuing coverage, if any, that participants receive after spinoff terminations. PBGC does not provide such information, however, and some 

plan terminations reported by PBGC in 1985 as spinoffs included working 

participants who received no continuing pension coverage or different 

coverage that may give them higher or lower benefits than before. 

t 

Health Facilities: New Nursing homes and hospitals in New York State are inspected by the 

York tate’s Oversight State Department of Health to ensure that the facilities comply with federal standards for participation in the Medicare and Medicaid programs. 

of Nu 

f 

sing Homes and These inspections are made under an agreement between the state and 

Hospi als (GAO/HRD- H”S* 

87-24 Nov. 28, 1986)* This report was prepared because of allegations concerning defects in 

the state’s inspection process-particularly in New York City-that 

could lead to the certification of substandard facilities to participate in 

the programs, thereby resulting in beneficiaries receiving $ubstandard 

care. 

GAO’S review did not substantiate the allegations. GAO did identify, however, some problems with the state’s processes for inspecting facilities 

and investigating complaints about them. 

Medicare: Need to > 

Stren’ then Home elderly, Medicare paid about $1.7 billion for home health care services in 

Healt it Care Payment 

fiscal year 1986-more than six times the amount paid ini1976. The 

Medicare home health benefit is intended to provide skilled nursing 

Contrbls and Address assistance to the elderly. In addition to medical services, the benefit covunmet Needs (GAO/ 

ers personal care and, to a limited extent, homemaker services (such as 

washing clothes and preparing meals). 

HRDP 

7-9, Dee, 2, 

1986 * Because adequate alternative sources of home care services are lacking, 

the Medicare home health benefit is also being used to meet the needs of 

the chronically ill. Limiting this benefit to short-term assistance could, 

Page 9 GAO/HRD-88-42 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1996, Through 

September 39,1987 

therefore, increase the unmet home care needs of chronically ill persons. 

The rapidly expanding elderly population heightens the need to consider 

alternative ways to meet these needs. 

Reviews by GAO in 1981 and by HHS in 1984 identified material weaknesses in internal controls over payment for Medicare home health services. This report states that HHS has been slow to implement changes to 

strengthen management controls in response to GAO'S 1981 

recommendations. 

This report also summarizes concerns expressed by the home health 

industry and others about the effects tighter program controls would 

have on Medicare beneficiaries’ ability to obtain needed home care services. GAO points out that HHS, however, has not evaluated available data 

to determine what effect stronger controls would have on unmet need 

for home health care assistance. 

Sbcial Security 

isability: 

I iIn plementation of the 

edical Improvement 

tieview Standard 

(@AO/HRD-87-3BR, 

Qec. 16, 1986)* 

This briefing report discusses SSA'S and the state DDSS' implementation of 

the medical improvement review standard, which resulted from the 

Social Security Disability Benefits Reform Act of 1984. 

GAO provides information on SSA'S efforts in resuming CDHS and its future 

plans for conducting these reviews. 

Medical Malpractice: 

Six State Case Studies 

Show Claims and 

Irkurance Costs Still 

Rise Despite Reforms 

(GAO/HRD-87-2 1, 

I$x. 31, 1986) 

During the mid-1970’s, the unavailability and increasing cost of medical 

malpractice insurance prompted 49 states to enact various reforms. GAO 

obtained views of organizations representing physicians, hospitals, 

insurers, and lawyers in six selected states on perceived malpractice 

insurance problems, such as the cost and availability of insurance, 

number of claims filed, and size of malpractice awards/settlements; 

actions taken to deal with them; the results of these actions; and the 

need for federal involvement. 

GAO reported that reforms to deal with medical malpractice problems 

can focus on changing the tort system, changing the way public bodies 

and peer groups regulate health care providers, changing the way the 

insurance industry is regulated, and developing realistic consumer 

Page 10 GAO/HRibR8-42 GAO Aging Activities in Fiscal Year 1987 

i..; j ‘_ ‘, ,.‘, 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1996, Through 

September 30,1987 

expectations about the health care delivery system. Most of the changes 

made by the six states to respond to the crisis of the mid-1970’s focused 

on tort reforms designed to assure the availability and to reduce the cost 

of malpractice insurance. 

While it is possible that the reforms which focused on changing the tort 

laws moderated upward trends in some states, GAO data showed that 

since 1980, insurance costs for many physicians and hospitals increased 

dramatically, as did the number of malpractice claims filed and the 

average amounts paid. 

I 

Medidal Malpraciice: Although medical malpractice insurance rates have increased since 

1980, the cost of this insurance for physicians and hospitals in Arkansas 

was not viewed as a major current problem by the six interest groups 

GAO surveyed. Major problems were expected to develop in the future, 

however, regarding the cost and availability of malpractice insurance, 

legal expenses/attorneys’ fees for malpractice claims, and physicians’ 

actions to reduce or prevent malpractice claims. 

Although the state enacted some tort reforms to address medical malpractice problems, the interest groups GAO surveyed believed the 

reforms had not had much effect. There was little support for federal 

involvement in the medical malpractice situation in Arkansas, and most 

groups believe that problems should be addressed at the state rather 

then the federal level. 

Medidal Malpractice: 

Case Study on 

Califdrnia (GAO/HRD87-21 

B 

-2, Dec. 31, 

1986)~ 

I 

, 

California health care and insurance officials that GAO contacted generally believe that the state’s comprehensive 1975 medical malpractice 

legislation, which has survived numerous constitutional challenges, has 

helped to moderate increases in malpractice insurance costs and malpractice awards/settlements. These officials told GAO that they expect 

the legislation to have a greater effect in the future since the California 

Supreme Court has upheld the major provisions as constitutional, and 

the U.S. Supreme Court has twice refused to hear cases regarding this 

legislation. Despite these efforts, however, physician and hospital malpractice premiums are continuing to rise, as are the number and size of 

malpractice claims and settlements. 

The California Trial Lawyers Association believed that legislation had 

impaired the rights of the malpractice victim to receive fair compensation for injuries caused by health care providers’ negligence. 

Page I1 GAO/HRD-8842 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued Prom October 1,1986, Through 

September 30,1987 

California’s health care providers and malpractice insurers still believe 

that there are major problems in the state regarding (1) the high cost of 

malpractice insurance, (2) the excessive size of malpractice awards/settlements, (3) the high legal costs associated with defending claims, and 

(4) the incentive to perform medically unnecessary procedures to reduce 

the risk of liability (i.e., defensive medicine). 

There was no widespread support for any federal involvement among 

the groups GAO surveyed. Officials generally believed that malpractice 

problems should be addressed at the state level. 

edical Malpractice: 

s ase Study on Florida 

( AO/HRD-87-2 IS-3, 

ec. 31, 1986) 

Florida’s medical malpractice insurance crisis in the mid-1970’s was one 

of availability, largely due to the withdrawal or threatened withdrawal 

of several large medical malpractice insurers in the state. By the mid1980’s, the problem had shifted to one of affordability. 

The Florida legislature responded with legislation in 1974, 1975, 1976, 

1985, and 1986. None of the interest groups GAO surveyed believed that 

the tort reforms enacted in the mid-1970’s have had a major effect on 

the cost of insurance, the frequency of claims, and the size of awards/ 

settlements. GAO data showed that the cost of insurance increased 

greatly between 1980 and 1986 and the frequency and size of claims 

also increased between 1980 and 1984, but somewhat less significantly. 

Regarding the 1985 legislation, representatives of several interest 

groups believe certain aspects of the act, such as increased emphasis on 

risk management and disciplinary measures against physicians with 

malpractice histories, will have some benefit. A majority of the groups 

GAO surveyed expressed support for several provisions of the 1986 act, b 

such as a cap on awards for pain and suffering and’the elimination of 

joint and several liability for the noneconomic portion of damages. 

& Medical Malpractice: 

Case Study on Indiana of 1975 and subsequent amendments have greatly stabilized the malpractice insurance situation during the past 11 years by holding down 

(GAO/HRD-87-2 lS-4, premium costs and attracting additional companies into the state marDec. 31, 1986) ket. They pointed out that insurance costs for Indiana physicians and 

” hospitals, before increases in 1985, were among the lowest in the nation, 

compared to the mid-1970’s, when they were higher than most neighboring states. 

Page 12 GAO/HRD-88-42 GAO Aging Activities in Fiscal Year 1987 
AppendLx 1 

GAO Reporta Ma&g to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 80,1987 

A key provision of the act was the establishment of the Patient’s Compensation Fund to pay malpractice awards or settlements in excess of 

$100,090, up to a $600,000 cap. To participate, physicians and hospitals 

pay a surcharge based on the premiums paid to their insurance companies for the basic coverage. Indiana officials were concerned that the 

increasing number and size of payments from the fund might adversely 

affect its solvency. According to the Indiana Department of Insurance, 

the fund was kept solvent in 1984 only by a transfer of $7.2 million 

from the reserves of the state’s medical malpractice joint underwriting 

association. 

Several actions have been taken in recent years to strengthen the fund’s 

ability to remain solvent. These actions include (1) increasing 

surcharges, (2) allowing the Department of Insurance to hire privatesector lawyers and other personnel to help defend claims against the 

fund, and (3) permitting periodic payments in lieu of lump-sum 

payments. 

Medical Malpractice: New York’s medical malpractice insurance crisis in the mid-1970’s was 

Case btudy on New one of availability, primarily due to the withdrawal of two large insurers. I3y the 1980’s, the problem shifted to affordability, as companies 

York (GAO/HRD-87- raised their rates. The New York state legislature responded to malprac21S-5, Dec. 31, 1986) tiec insurance problems by several legislative initiatives-the latest in 

19% and 1986. Although it is too early to tell how effective the latest 

reform will be, insurance rates have continued to climb for hospitals and 

physicians, particularly for high-risk specialties. The rates are among 

the highest in the nation. 

Of the interest groups surveyed, New York’s Hospital Association, Bar 

Association, and the Trial Lawyers Association supported additional 

actions to strengthen licensing and relicensing of physicians. To regulate 

the profession, the New York Bar Association favored seqting insurance 

rates for physicians according to their malpractice claims and loss 

experience rather than revoking physician licenses. 

There was no agreement among the interest groups surveyed that the 

federal government should assume a role in addressing medical malpractice insurance problems. Only the physician organizations surveyed supported a federal role to develop a uniform system for resolving medical 

malpractice claims. 

Page 18 GAO/HRD-88-42 GAO Aging Activities in Rscal Year 1987 

,:i ‘, 

:‘. 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 30,1987 

Medical Malpractice: 

@se Study on North 

Ckwolina (GAO/HRD8t-21S-6, Dec. 31, 

1 86)* 

[ 

Since 1980, medical malpractice insurance premiums have increased significantly for physicians and hospitals in North Carolina. The frequency 

of claims and the average paid claim also increased between 1981 and 

1984 for physicians and hospitals. 

Several interest groups identified major current medical malpractice 

problems regarding the increasing size of malpractice awards/settlements, the equity of awards/settlements for malpractice claims, and 

legal expenses for malpractice claims. The groups expect these problems 

to continue and anticipate that the cost of malpractice insurance and the 

number of claims filed would become major problems in the future. To 

address malpractice problems, four of the six interest groups GAO contacted strongly supported use of risk management programs designed to 

reduce the incidence of malpractice claims by eliminating problems that 

result in those claims. 

The groups surveyed by GAO supported state rather than federal actions 

to address malpractice problems. 

Posthospital Care: In this report, GAO summarizes information obtained from hospital discharge planners regarding their perceptions about problems in placing 

Medicare patients in posthospital care and the reasons for those 

problems. 

This information was collected in a sample survey of 935 Medicare certiMedicare Patients fied acute care hospitals. To GAO'S knowledge, it is the first nationally 

(C+AO/PEMD-87-5BR, representative study of changes believed to be occurring in Medicare 

J@. 23,1987) patients’ access to posthospital care. 

Mkntal Health Care: 

Licensing and 

In this fact sheet, GAO reported information from 39 states on the minimum licensing and certification requirements for physicians, psychiatrists, psychologists, social workers, and nurses who work directly with 

Qrtification patients in state mental hospitals. 

Rkquirements for Staff The minimum licensing and certification requirements for these profesin! State Hospitals sionals varied among the 39 states. 

(qAO/HRD,87-38FS, 

J@II. 29,1987) 

Page 14 GAO/HRD88-42 GAO Aging Activities in Fiscal Year 1987 
Appendlx I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1988, Through 

September 30,1987 

Medicare: More To help control rising Medicare costs, the Congress has required that, in 

certain cases, health and accident insurers covering Medicare beneficiaries pay medical claims ahead of Medicare. While the percentage of 

beneficiaries having insurance that pays before Medicare is relatively 

small (an estimated 4 percent), hundreds of millions of dollars in annual 

savings is achievable by billing such coverage. 

In this review, GAO sought to determine whether HHS, which administers 

Medicare, could improve existing policies and procedures for identifying 

and billing other insurers that should pay for hospital claims before 

Medicare. GAO identified the problems that appeared to be the main hindrances to a more effective system for identifying and billing primary 

insurers and made several related recommendations to HHS. 

I 

1 Socia Security: 

Dem cl nstration 

Proje’ ts Concerning 

Inter 

l/ 

iews With 

SSA’S demonstration projects involve interviews with disability claimants at the initial decision level, before a final unfavorable decision is 

Disa ility Claimants 

mandated by the Social Security Disability Benefits Reform Act of 1984. 

(GA /HRD-87-35, 

Feb. 9,1987)* 

f 

made by the state disability agencies. The claimants are initial applicants and beneficiaries whose claims are being examined for eligibility 

through continuing disability reviews. The demonstration projects were 

For this report, GAO discussed implementation with officials from SSA 

and participating states, reviewed the scope of work for the contractor 

hired by ss~ to evaluate the projects, and reviewed the contractor’s 

design and analysis plan. 

GAO found certain factors that may detract from a successful demonstration and made several recommendations to SSA to help ensure that the 

demonstration and its evaluation provide the Congress with objective 

and meaningful data. 

Health Facilities: GAO obtained information on the Harlem Hospital Center’s compliance 

Problems at Harlem with Medicare standards and determined the actions the New York State 

Hospital in Complying 

Department of Health and HHS'S Health Care Financing Administration 

( HCFA) have taken in response to deficiencies found at the hospital. 

With Medicare 

Standards (GAOIHRD- These deficiencies were persistent and serious, with many involving 

actual or potential patient harm. As a result, the state fined the hospital 

87-5 , Feb. 20,1987) for violating state hospital standards, and the hospital agreed to a corrective action plan. In addition, HCFA, which administers Medicare, (1) 

concluded that the hospital was not meeting Medicare standards and (2) 

Page 16 GAO/HRD-89-42 GAO Agiug Activities in Fiscal Year 1987 
Appendix I 

GAO Reports Relating to kssaee Affecting the 

Elderly Issued From October 1,1@86, Through 

September 30,1987 

directed the state, which serves m HCFA'S agent, to monitor the actions 

the hospital had taken to correct its deficiencies. 

Budget Reduction: 

Effect of 1986 

questration on 

N 7 tional Institute on 

Aging (GAO/HRD-87- . 

5TBR, Mar. 6, 1987) 

. 1 

. 

. 

Under the Balanced Budget and Emergency Deficit Control Act of 1985, 

known as the Gramm-Rudman-Hollings Act, the National Institute on 

Aging’s (NIA) fiscal year 1986 budget authority was reduced by 4.3 percent. In congressional testimony on the potential effects of this reduction, the Director of NIA anticipated that 

the reduction would result in each of NIA’S seven budgetary line items 

being reduced by 4.3 percent, 

the total number of research grants would be reduced, 

the funding for the Alzheimer’s disease research centers could not be 

protected, and 

delays would occur in funding certain Alzheimer’s disease research 

projects. 

In response to a congressional request, GAO reviewed NIA budget and 

grant information and interviewed various NIA officials and found that 

although the overall appropriation of $156.5 million was reduced by 4.3 

percent, or 6.7 million, the anticipated effects did not materialize. 

In 1985, providing medical care for low-income persons through the federally funded, state-administered Medicaid program cost about $38 billion Resulting financial strains on both the federal and state 

governments have sparked national interest in ways to constrain these 

costs. 

M/edicaid: L,essons 

L&arned From 

Abzona’s Prepaid 

Ptiogram (GAO/HRD8%14, Mar. 6, 1987) 

. 

I 

/ I 

One experiment to limit Medicaid costs is Arizona’s Health Care Cost 

Containment System, under which the state contracts with prepaid 

health plans to provide comprehensive medical care for a set monthly 

fee per patient. 

GAO reviewed the program’s first 3 years of operation (Oct. 1982-Sept. 

1985) to examine Arizona’s approach to 

. competitive bidding for procuring health plan contracts, 

l collection of utilization data from the prepaid plans on the health care 

services provided, and 

l financial oversight of the prepaid health plans. 

Page 16 GAO/HRD8842 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 30,1987 

The Arizona program experienced numerous start-up problems that prevented an assessment of the effectiveness of its cost containment feature. GAO believes other states considering prepaid Medicaid programs 

can learn from Arizona’s problems and solutions. 

Insu 

; 

ante Reserves: 

Stra egies for 

Reg lating the Federal 

Emp “r oyees Health 

Ben 

a 

fits Program 

(GA /HRD-87-10, 

Mar.16, 1987)* 

The Federal Employees Health Benefits Program (FEIIBP) is administered 

by the Office of Personnel Management (OPM) through contracts with 

participating health plans. In 1985, the program insured more than 8 

million federal employees, annuitants, and dependents through 2 12 

health plans that received about $6.4 billion in premiums. 

In 1985, FEHBP reserves were record-breaking, accumulating more than 

$2 billion in reserve surplus and precipitating the program’s first 

refund. Just 4 years earlier, certain FEHBP health plans faced financial 

difficulties because their reserve holdings were near depletion. 

FEHBP reserves have fluctuated widely from their targets, needing frequent and often substantial adjustments to keep them at, or near, the 

preferred levels. With the number of uncertainties inherent in estimating health care costs, GAO doubts that OPM and the plans can set premiums accurately enough to avoid these reserve fluctuations, 

Consequently, OPM needs to use the best means available to equitably 

adjust reserves. 

OPM and the plans have three strategies to regulate reserves-adjusting 

future premiums, modifying future benefits, or giving refunds. These 

strategies can also be used in combination. In GAO'S opinion, adjusting 

future premiums is the best strategy. 

Socikl Security: Staff 

Redtictions and 

Service Quality (GAO/ 

HRDi-87-66, Mar. 10, 

198q) ! 

/ 

/ 

/ 

In January 1985, the administration announced its intention to reduce 

SSA staff by 17,000, or 21 percent, through fiscal year 1990. 

This is the first of three required reports on SSA staff reductions and the 

quality of service provided to the public. The report (1) discusses 

changes in traditional ss~ service level indicators, such as payment accuracy and claim processing time; (2) analyzes current and past SA staffing levels; (3) presents the views of SSA employees, managers, and clients 

on the quality of %A service; (4) analyzes workloads and processing 

times for 15 SSA field offices that experienced significant staff reductions; and (5) examines SSA staff reduction actions in implementing its 

fiscal year 1987 budget. 

Page 17 GAO/HID-884 GAO Aging Activities in Fiscal Year 1987 

. 
Appendix I 

GAO Reporta Relating to Issues Affecting the 

Elderly Issued Prom October 1,1986, Through 

September 36,1987 

Overall, SSA’S traditional performance measures through December 1986 

generally showed stable performance since fiscal year 1984-the year 

before the start of the staff reduction program. Similarly, about 80 percent of ss~ clients GAO surveyed said that overall the quality of SSA service was good. GAO found that the 6-year staff reduction program is 

generally on schedule. 

inistration: Stable 

Mdnagement Needed 

(GAO/ 

D-87-39, Mar. 18, 

1987) 

In fiscal year 1986, SSA employed about 78,000 people and spent $3.9 

billion to administer programs that paid $200 billion in benefits to about 

37 million people. While aspects of social security policy, such as eligibility or benefit levels, have always received public and congressional 

attention, less attention has been given to SSA'S management. 

GAO reviewed SSA’S management of its program operations and found 

that SSA has serious management problems that, while not clearly visible 

to the public, have contributed to crisis situations in the past and could 

interfere with SSA'S ability to effectively accomplish its mission in the 

future. 

This report contains many specific recommendations to the Social Security Commissioner to improve management of the agency, but the most 

important recommendations are to the Congress and the President. 

Pebsion Plans: 

Gdvernment Insurance 

P&gram Threatened 

by i Its Growing Deficit 

(GAO/HRD-87-42, 

Mar. 19, 1987)” 

I I / 

‘S7 

The Employee Retirement Income Security Act of 1974 established 

funding standards and an insurance program to protect the benefits of 

about 30 million participants in over 110,000 single employer defined 

benefit pension plans. As of September 1985, the insurance program 

reported a deficit of $1.3 billion, but in January 1987 the deficit was 

estimated to be about $4 billion. The Single Employer Pension Plan I, 

Amendments Act of 1986 included provisions to improve the program’s 

financial condition. In this report, GAO assessed the causes of large 

claims against the program and the potential effects of the 1986 amendments on the program. 

GAO concluded that the positive effects of the 1986 amendments may not 

be enough to ensure the program’s long-term financial viability and further changes may be needed to control program claims and finance those 

that do occur. 

Page 18 GAO/~8842 GAO Agiug Activities in Fiscal Year 1987 

‘,’ ,l,“ , i., 
Appendix I 

GAO Repwts Relating to Issues Affecting the 

Elderly I~lsued From October 1,1986, Through 

Sk’ptember 80,1987 

Medibare and 

Medikaid: Effects of 

During the 1970’s, Medicare and Medicaid program costs grew rapidlyMedicare costs rose from about $6.9 billion in fiscal year 1970 to about 

$28.2 billion in fiscal year ” 1979, while Medicaid expenditures rose from 

Rece t Legislation on about $4.6 billion to about $20.5 billion. During the following 7 years, 

Prog am and 1980-86, the Congress enacted more than 30 laws that affected these 

Bene 

i 

iciary Costs 

two health insurance programs. 

(GA /HRD-87-53, This report provides GAO'S analyses of the effects of major legislative 

Apr. 8, 1987)* changes from 1980 to 1986 on Medicare and Medicaid program costs and 

the out-of-pocket costs to the programs’ beneficiaries. 

I 

I Medi@id: Addressing Established as a partnership between the federal and state governthe Fjeeds of Mentally ments, Medicaid finances care for the retarded in nursing homes. In 

addition to meeting the medical needs of their residents, nursing homes 

Reta 

H 

ded Nursing are required to provide services to their mentally retarded residents to 

Horn Residents help them function independently. 

(GA(p/HRD-87-77, This report discusses GAO'S review of Medicaid management controls 

Apr. 15, 1987) and whether they adequately ensure that mentally retarded nursing 

home residents receive the services they need to help them function 

independently. In its review of three states’ nursing homes, GAO found 

that mentally retarded residents’ active treatment needs were not being 

identified and met. 

I 

Medxal Malpractice: Since national data on medical malpractice claims had not been collected 

Chatacteristics of since 1978, GAO undertook a review to obtain information that would 

answer the following questions: 

Claims Closed in 1984 

(GAQ/HRD-87-55, . How many malpractice claims were closed’? 

Apr.: 22, 1987) l IIow many health care providers were involved? 

. What were the allegations of negligence leading to the claims‘? 

l Ilow much was paid to those who filed claims? 

9 What were insurers’ costs to investigate and defend the claims? 

To do this review, GAO analyzed data from a random sadple of malpractice claim files closed in 1984 by 25 insurers. The insure@ were randomly selected from a universe of 102 insurers that wrc$e a total of $2.3 

billion in direct premiums in 1983 for medical malpractice insurance. 

I “#ii 

Page 19 GAO/HRD-8842 GAO Aging Activities in Fiscal Year 1987 

1’ *I’ , ’ 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 30,1987 

Medicaid: Determining 

‘St-Effectiveness of 

and Communityed Services (GAO/ 

Apr. 28, 

In passing the 1981 Omnibus Budget Reconciliation Act, the Congress 

authorized adding home and community-based services to the Medicaid 

program through the use of waivers. The intent was to offer alternatives 

to nursing home care without increasing Medicaid costs. In principle, by 

providing certain kinds of social services (such as help with cooking, 

housekeeping, or such personal care needs as bathing) to people living in 

the community, nursing home care can be avoided or postponed. 

To provide these alternative services, traditional Medicaid requirements 

must be waived by the Secretary of HHS. The state must assure HHS that 

its estimated Medicaid costs with the added home and community-based 

services will not exceed its estimated costs had no waiver been 

approved. To evaluate the costs experienced by these alternative care 

programs, HCFA, the HHS component that administers Medicaid, requires 

states granted waivers to report cost and recipient data. 

GAO reviewed reports from the states on the Medicaid home and community-based services program to see if accurate, complete, and useful 

information was being collected. GAO reported that HCFA had not 

obtained the information necessary to evaluate the Medicaid home and 

community-based services program. Information collected during the 

first 5 years of the program has been neither accurate nor consistently 

reported and consequently is not useful for evaluating the operating 

experience of most waiver programs. 

To remedy these shortcomings, HCFA recently revised its reporting 

requirements and instructions. GAO believes the changes will improve 

the accuracy and usefulness of states’ reports but recommended that 

HCFA develop information to measure the extent to which the program 

prevents or postpones the use of nursing home care. Without such infor- b mation, the program’s cost-effectiveness cannot be adequately 

evaluated. 

Health Care: Patient 

Trbnsfers From 

There have been many changes in the past 3 or 4 years concerning the 

way hospitals are reimbursed for care by the government and private 

Edergency Rooms to 

insurers. Consequently, one of the concerns of many people has been 

that private hospitals may be “dumping” patients on public hospitals to 

D.C. General Hospital escape having to treat people who may not have the financial means to 

(GAO/HRD-87-3 1, 

pay for their care 

Apr. 30,1987)* District of Columbia law requires that D.C. General Hospital treat all 

Washington, D.C., residents regardless of their ability to pay for the care 

Page 20 GAO/HRD-88-42 GAO Aging Activities in Fiscal Year 1987 
- 

Appendix I 

GAO Report.8 Relating to Issues Affecting the 

Elderly Isuued From October 1,1986, Through 

September 30,1987 

received. The D.C. government provides the hospital with funds to offset the cost of treating these residents. The hospital has adopted a transfer policy and procedures outlining the conditions under which it will 

accept transfers of D.C. residents from other hospitals’ emergency 

rooms. 

This report discusses 

l the policy and procedures for transferring patients from other hospitals’ 

emergency rooms to D.C. General, 

. Washington metropolitan area hospitals’ violations of the transfer policy and procedures, 

l Washington metropolitan area hospitals’ familiarity with the policy and 

procedures, 

l characteristics of patients transferred to D.C. General, and 

. how professional medical organizations view transfers and how other 

metropolitan areas across the country deal with them. 

The Medicaid program is jointly financed with state and federal funds. 

ns in Benefits 

D-87-67BR? 

The latter are determined by a statutory formula that provides a higher 

federal share to states with lower per capita incomes, Within broad federa1 guidelines, each state designs and administers its own Medicaid program. Consequently, significant interstate variations exist along 

important program dimensions. 

This briefing report provides information on the causes of interstate 

variations in Medicaid spending and the growth in overall spending. 

Using published and unpublished information, GAO identified trends and 

wide variations among states in Medicaid spending and compared (1) 

eligibility criteria used, (2) the scope of services offered, and (3) reimbursement to providers. GAO also reviewed and summarized other studies analyzing the underlying causes of the variations identified. 

, 

I Medical Malpractice: A Because of increases in the costs of medical malpractice insurance over 

Frarrjework for Action several years, GAO was asked to assess the nature of the problems, how 

various states have tried to deal with them, and what federal and state 

(GACj/HRD-87-73, actions may be warranted. The purpose of this report, the final one in a 

May PO, 1987)* series of five, was to suggest actions that appear to GAO to be appropriate beginnings to address medical malpractice problems. 

Page 21 GAO/HRD-88-42 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reporta Relating to Issuea Affecting the 

Elderly Iseued From October 1, 1980, Through 

September 30,1987 

Overall, GAO'S work showed that there are no clear causes for the 

increases in the cost of medical malpractice insurance. And there is no 

specific action that GAO could identify that would guarantee that insurante rates will not continue to increase. 

But GAO suggests actions that all affected parties could take that have 

some promise of reducing the cost of insurance. These actions include 

reducing the incidence of medical malpractice by ensuring that physicians are held accountable by their peers and others for the manner in 

which they practice medicine; improving efficiency, predictability, and 

equity in the way medical malpractice claims are resolved; determining 

the extent to which regulatory agencies have and use information to 

make decisions about ,rates and solvency; and better educating patients 

as to what their expectations should be from the health care system. 

-I 

Long-Term Care In 1988, estimated nursing home expenditures will exceed $46 billion, of 

Insurance: Coverage 

Varies Widely in a 

Developing Market 

which the elderly and their families will pay about half. Private longterm care insurance is one method of financing these potentially catastrophic expenses. 

The Medicare program and private Medicare supplemental insurance 

provide limited nursing home coverage for skilled care services. State 

Medicaid programs cover extended nursing home stays associated with 

chronic, debilitating disease, but only for those who meet strict eligibility standards based on income and resources. 

Unlike the Medigap insurance market, no federal legislation defines 

guidelines for the long-term care insurance market. In this report, GAO 

provides information on the private long-term care insurance market. b 

GAO focuses on policy benefits and premiums, policy limitations and 

restrictions, and the potential for abuse in the market. 

Page 22 GAO/HRDS842 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Ueporta Relating to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 30,1987 

Social’ Security: Staff 

Reduqtions and 

Serviae Quality (GAO/ 

HRD- 7-97BR, June 2, 

1987) 

: 

This briefing report was the second of three reports on staff reductions 

and service quality at SSA. Overall, SSA reduced its staff by 3 percent in 

the first half of fiscal year 1.987, with field offices taking the largest 

reduction-about 5 percent. 

In most cases, GAO found that SSA'S key performance indicators showed 

stable or improved performance. For example, pending workloads for 

disability claims were down, processing times for initial claims were virtually unchanged, and Supplemental Security Income processing accuracy was slightly higher. 

In other cases, GAO noted apparent temporary or seasonal declines in SW 

performance. For example, due to a significant increase in requests for 

hearings, the pending hearings workload and the average processing 

time for hearings had increased. 

VA H alth Care: 

Fina cial and Quality 

Cont 01 Changes 

Need d in Domiciliary 

Care GAO/HRD-87- 

- 

57, J ne 18,1987) 

As part of its national health care system, the Veterans Administration 

(VA) operates 16 domiciliaries. VA has described domiciliary care as less 

intensive than hospital and nursing home care, but higher than that provided in a residential setting. During fiscal year 1986, VA domiciliaries 

operated about 7,000 beds at a cost of about $100 million. 

Based on its review of three domiciliaries, GAO estimated that about 29 

percent of the veterans had incomes that exceeded the $415 a month 

eligibility limit. However, the income limit for domiciliary eligibility has 

not been updated since 1980 and is significantly lower than limits for 

other VA health care programs. 

In addition, the three domiciliaries had not always documented whether 

physical examinations had been performed and treatment plans properly developed. GAO could not conclude that the domiciliaries’ lack of 

compliance with the required procedures affected the quality of care 

provided. GAO believes, however, that the lack of compliance increases 

the likelihood that veterans’ medical needs would not be met. 

Page 23 GAO/HRD-88-42 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reports Relatlug to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 30,1987 

Medicare: Comparison 

Catastrophic Health 

surance Proposals 

( AO/HRD-87-92BR, 

J f ne 19,1987) 

Public programs- financed primarily by Medicare, Medicaid, and VAfinanced two-thirds of the elderly’s estimated $120 billion in personal 

health care expenditures in 1984. Although the scope and coverage of 

medical services under Medicare is broad, considerable beneficiary cost 

sharing is required. Also, some health care expenses-such as outpatient drugs; vision, hearing, and dental care; and care provided in intermediate or custodial care facilities-are not covered at all. 

Currently, there is no catastrophic limit on medical expenses paid by the 

beneficiary. The Secretary of HHS has described catastrophic illness 

expenses as those that cannot be borne by individuals and families without having to significantly change their life style or drastically modify 

their expectations of living standards in the future. 

GAO reviewed 14 legislative proposals and found that 9 would establish a 

catastrophic limit above which the beneficiary would no longer be liable 

for Medicare deductibles and coinsurance. Two of the legislative proposals have been approved by the House Committee on Ways and Means 

and the Senate Committee on Finance; both have financing mechanisms 

that relate the amount beneficiaries pay for catastrophic coverage to 

their incomes. GAO reported that these bills, if enacted, would represent 

an important step in increasing the health insurance coverage available 

to the elderly, but significant gaps will remain. Providing further relief 

to the elderly who incur high out-of-pocket health care costs would obviously increase Medicare payments. 

Medicare: 

Rbhabilitation Service 

Claims Paid Without 

Adequate Information 

(GAO/HRD-87-91, 

Jtily 9, 1987) 

Since 1983, when Medicare began to phase in its hospital prospective 

payment system, outpatient rehabilitation has become an important 

alternative source of therapy because the system has given hospitals 

incentives to discharge beneficiaries to outpatient care as soon as medi- b 

tally appropriate. 

In 96 percent of its sample cases, GAO found that the documentation 

available to the claims-processing contractors when they paid outpatient 

rehabilitation services claims was insufficient to determine whether the 

beneficiary was eligible for these services. Many cases in the sample 

were of types indicating that services probably were not eligible for coverage. For example, 16 percent of the cases were for beneficiaries with 

diagnoses that HCFA has identified as normally having little rehabilitation potential. 

Page 24 GAO/HRD-88-42 GAO Aging Activities ln Fiscal Year 1987 
Appendix1 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October l,I9136, Through 

September 30,1987 

The report discusses HCFA'S actions to strengthen controls over payments for outpatient physical therapy and services provided, but GAO 

believes that unless the documentation of claims is improved, these 

actions will not solve the problems. 

I 

Medihare: Preliminary Medicare reimburses physicians, other practitioners, and suppliers on a 

fee-for-service basis and, until recently, paid all facility-based providers 

on a cost basis. This created incentives to overuse Medicare services. 

The introduction of a payment system based on prospectively determined fixed amounts for acute care hospitals and the growth of prepaid 

health care programs (health maintenance organizations and competitive medical plans) created new incentives to increase efficiency by 

reducing unnecessary or inappropriate care. GAO found that incentives 

to increase efficiency in the delivery of health services may lead to the 

withholding of some useful, needed services, and that Medicare payment 

reforms have increased the potential for quality-of-care problems. 

This briefing report summarizes GAO'S analysis of Medicare’s quality-ofcare review system. Also in this document GAO identifies four short-term 

options and outlines three long-term strategies for producing comprehensive quality-of-care information. 

Vetetans 

Adm nistration: 

i’ 

VA 

Pens, ons to Medicaid 

Nursbng Home 

Residents Should Be 

Rediced (GAO/HRD87-111, July 10, 1987) 

Under title 38 of the U.S. Code, a VA pension is reduced if the beneficiary 

enters a VA-supported nursing home and does not have a spouse or other 

dependent living in the community. A similar provision does not exist, 

however, when the beneficiary enters a nursing home as a Medicaid 

patient. 

Because Medicaid recipients must apply any cash income and benefits 

they receive toward the cost of their care, the VA pensions do not generally benefit veterans and their survivors. Instead, they reduce Medicaid 

program costs. The primary beneficiaries of the reduced Medicaid costs 

are the states. 

In this briefing report, GAO estimated, based on its review, that in fiscal 

year 1986, continuing VA pension payments to about 18,500 Medicaid 

nursing home residents in the eight states selected for this review cost 

the federal government about $27.2 million. 

Page 26 GAO/HRD-88-42 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 30,1987 

bcial Security: Clients This briefing report presents the final results of GAO'S November 1986 

ill Rate Quality of nationwide survey of client satisfaction with the quality of service provided by SSA and compares the results with a similar survey GAO conbrvice High (GAO/ ducted 2 years earlier. 

XD-87- 103BR, 

Ily 14, 1987) The 1986 survey was made because of concerns expressed about SSA services during implementation of the agency’s plan-announced in January 1985-to reduce staff by 17,000 full-time equivalent positions 

through fiscal year 1990. Staff was reduced by about 4,500 full-time 

equivalent positions between the two surveys. 

Comparing the results of the two surveys (using the same questionnaire 

for both) showed that clients rated the overall quality of service in 1986 

about the same as, or better than, the service provided in 1984. Notably, 

no specific service aspects were rated significantly lower by 1986 

respondents in comparison with 1984 respondents, and a number of 

aspects were rated higher. Several of the questions that drew more 

favorable responses in 1986 represented statistically significant 

differences. 

Block Grants: 

ental Health Provide 

J@y 16, 1987) 

In 1981, the Congress consolidated 10 project and formula grant programs into the Alcohol, Drug Abuse and Mental Health block grant. In 

fiscal year 1987, the current formula allocated over 91 percent of block 

grant funds to states based on their funding under the prior categorical 

programs, and the other 9 percent based on their relative funding needs 

and ability to pay. A draft bill would create separate programs for substance abuse and mental health, using separate formulas. Unlike the 

current formula, the proposed formulas would allocate all funds according to need and ability to pay and would use more precise measures of 

these two factors. 

b 

In this briefing report GAO concluded that the proposed formulas would 

substantially improve the equity of the distribution of federal funds. For 

substance abuse, they would help equalize service levels across states 

because higher funding levels would be allocated to states with the lowest spending and ability to pay. For mental health, the proposed formulas would preserve the targeting to poorer states that is provided by the 

current formula. Finally, in both substance abuse and mental health 

areas, the proposed formulas are designed to provide similar grants per 

person for states with similar abilities to pay. 

Page 26 GAO/HRD-M-42 GAO Aging Activities in Fiscal Year 1987 
I’ 

I 

,” 

Appendix1 

GAO Reporta Relating to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 30,1987 

Medicare: Prescription 

Drug’ Issues (GAO/ 

PEM -87-20, July 16, 

1987 * 

” 

I I / 

I 

That the prescription drug costs are rapidly rising is an important fact 

for the millions of the elderly suffering from such conditions as diabetes, 

high blood pressure, various heart conditions, and some types of cancer. 

Because they depend on medication to help control these problems, buying prescription drugs is a major out-of-pocket health care expense for 

them. 

This GAO report presents demographic information about prescription 

drug use and costs and then briefly discusses its coverage under Medicare, under Medicaid, and in states that have developed programs specifically to meet this need. The report also discusses how H.R. 2470 and 

S. 1127 would provide prescription drug benefits for the elderly and the 

population groups that would remain without benefits if these bills were 

enacted. 

I Medipare: Payments to This briefing report has information about the current Medicare payRadiQlogists, ment mechanism for radiologists, anesthesiologists, and pathologists and 

the market structure for services provided by these physicians. GAO also 

thesiologists, and looked at whether the financial interests of the Medicare program and 

its beneficiaries were considered when contracts were negotiated 

between hospitals and the physicians who specialize in these areas. 

Med’ 

f 

are and 

Med’caid: Stronger 

Enfokcement of 

Nursing Home 

Requirements Needed 

(GAp/HRD-87-113, 

Julyi22, 1987) / 

Y 

, 

Together, Medicare and Medicaid pay about half of the nation’s nursing 

home costs. Because of continuing concern about the quality of care provided to nursing home residents, GAO was asked to determine the extent 

of repeated noncompliance with federal requirements that could affect 

resident health and safety and evaluate the adequacy of federal and 

state enforcement actions to correct reported deficiencies. 

GAO reported that nursing homes can remain in the Medicare and Medicaid programs for years with serious deficiencies that threaten patient 

health and safety by taking corrective action to keep from being terminated each time they get caught. GAO analyzed the four most recent 

inspections (covering about a 4-year period) for nursing homes participating in the programs in November 1985. Forty-one percent of skilled 

nursing facilities and 34 percent of intermediate care facilities nationwide were out of compliance during three consecutive inspections with 

Page 27 GAO/HRD83-42 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 90,1987 

one or more of the skilled or intermediate care facility requirements considered by experts to be most likely to affect patient health and safety. 

Determining the actual effects on patients’ health and safety was 

beyond the scope of GAO'S review. 

Although a nursing home that has the same deficiencies in consecutive 

inspections without adequate justification should be terminated, according to Medicare and Medicaid regulations, neither HHS nor the states 

were enforcing this rule. No federal penalties currently apply to deficiencies, even if uncorrected, that do not pose an immediate threat to 

resident health and safety. The ability to avoid penalty even for serious 

or repeated noncompliance gives nursing homes little incentive to maintain compliance with federal requirements. 

GAO believes additional sanctions are needed to strengthen federal and 

state enforcement options. 

tastrophic Illness elderly and their families against the catastrophic expenses they may 

face when they have acute medical problems or when they need longterm care because of chronic illness and disabling conditions, such as 

stroke and Alzheimer’s disease. Despite Medicare benefits and private 

insurance supplements to that program, out-of-pocket expenditures for 

medical care substantially burden many. 

For this briefing report, GAO developed the following material: 

l A comparison of major legislative proposals with the current Medicare 

program with respect to benefits to enrollees, their costs, and the program’s financing mechanisms. 

b 

. A discussion of important issues that may still need !attention. 

l A synthesis of lessons learned from the operation of state-financed 

insurance programs for catastrophic illness that the ~Congress might consider in developing a federal program. 

Page 28 GAO/HRD-88-42 GAO Aging Activities in Piscal Year 1987 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1980, Through 

September 30,1987 

Pensi’ n Plans: Many 

Work rs Don’t Know 

Whe They Can Retire 

(GAO HRD-87-94BR, 

Aug. 

; 

2, 1987)” 

Millions of workers do not understand their pension plans’ early and 

normal retirement eligibility requirements as described in their plans’ 

documents. 

GAO focused its review on assessing workers’ knowledge of their pension 

plans, but it did not determine the causes for their lack of knowledge, 

nor did it address the extent to which this lack of knowledge could 

result in poor career and retirement planning decisions. GAO concluded, 

however, that unless employers provide and workers obtain accurate 

pension plan information before workers make decisions affecting their 

careers, the workers may make work and retirement decisions they later 

regret. 

I 

Protecting the Elderly: Certain “aging organizations” have attempted to solicit funds, sell insurFederBal Agencies’ Role ante, and offer direct-mail advertising of products in a manner that may 

frighten, threaten, or otherwise coerce the elderly into contributing 

Concerning money or buying products from these organizations. 

In this fact sheet, GAO (1) identifies federal agencies with jurisdiction in 

reviewing the activities of organizations that use direct-mail advertising, 

(2) identifies federal statutes or regulations these agencies may use to 

protect the elderly, (3) discusses current activities of these agencies to 

protect the elderly, and (4) discusses agency educational activities to 

prevent possible abuses of the elderly. 

Medikaid: 

Imprbvements Needed 

in Pr$grams to 

Prevent Abuse (GAO/ 

HRDj87-75, Sept. 1, 

1987) 

I 

, 

A small percentage of recipients and providers abuse Medicaid services. 

Abuse occurs when a provider prescribes services that are not needed or 

are too expensive or when a Medicaid recipient obtains drugs or other 

services at a frequency or in an amount not medically necessary. 

The Medicaid law requires states to identify and investigate cases of 

suspected Medicaid abuse by reviewing recipients’ and providers’ use of 

Medicaid services. To facilitate reviews, in fiscal year 1985, state and 

federal costs for design, installation, and operation of the computerized 

information systems to operate the programs were about $430 million. 

Although GAO and others have previously identified weaknesses in 

states’ postpayment utilization review programs and HHS'B oversight, 

GAO concluded HHS has not taken effective action to strengthen management controls. GAO found (1) some states reviewed were not effectively 

using their computerized management information systems to identify 

Page 29 GAO/HRD-8842 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reporta Relating to Issues Affecting the 

Elderly Issued From October 1,1996, Through 

September 30,1987 

potential Medicaid abuse, (2) some states were reviewing only a small 

portion of the potentially abusive recipients identified, and (3) most 

states have applied sanctions against few abusive Medicaid recipients. 

Sbcial Security: SSA offices may be contacted by the public through 34 teleservice centers 

(SSA’S primary telephone service facilities), 32 other central answering 

units, and telephone service directly from 627 local offices that are not 

supported by centralized answering facilities. 

GAO tested accessibility to SSA by telephone by measuring the extent to 

which telephone calls to SSA’S local offices and teleservice centers during 

a single workweek were answered directly, put on hold before being 

answered, got a busy signal, went unanswered, or were disconnected. 

SSA representatives answered, during the test period, about two of every 

three calls from the public directly or within 2 minutes of being put on 

hold, by GAO estimates. As a group, local offices were more easily accessible than teleservice centers. Success in reaching SSA fluctuated by day 

of the week, with Monday being the most difficult day for getting calls 

answered. 

This briefing report was the last of three reports on staff reductions and 

service quality at SSA during fiscal year 1987. It describes changes in 

staffing and performance for the third quarter of fiscal year 1987 and 

presents the results of GAO visits to 13 offices where allegations had 

been made about practices affecting reported office performance. 

GAO reported that overall, key performance indicators showed stable 

performance as staff levels continued to decline. During GAO'S visits to b 

the 13 offices, SSA employees said that practices that can distort 

reported performance are occurring. But employees ‘held a wide range of 

views as to the extent to which these practices were occurring. Internal 

controls to detect the practices generally rely on supervisors and office 

managers to monitor employees’ work. While the potential exists, GAO 

found little evidence that the practices were used to conceal any direct 

harm to the public. 

GAO determined that it is unclear to what extent the root causes of these 

improper practices were local management shortcomings, poor employee 

performance, or other factors cited by employees, such as insufficient 

staff or overemphasis on achieving certain productivity goals. 

Page 30 GAO/HRD-88-42 GAO Aging Activities in Fiscal Year 1987 
sociz 

Must 

Cred 

Indit 

(GA( 

Sept. 

AppendLxI GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 30,1987 

Security: More 

3e Done to 

Earnings to 

duals’ Accounts 

‘HRD-87-52, 

-8, 1987) 

Employers report employees’ earnings to SSA and the Internal Revenue 

Service (IRS) at different times and for different purposes. IRS compares 

the annual total earnings employers reported to SSA for each employee 

with the total of the quarterly earnings employers reported to IRS. Subsequently, IRS tells SSA which employers may not have reported any or 

all earnings to SSA. In many cases, contacts with the employers are necessary to determine whether all earnings were reported. 

GAO reported that the slow progress by SSA and IRS in reconciling differences in employee earnings has resulted in (1) Social Security beneficiaries receiving less in benefits than they were entitled to and (2) the 

Social Security trust funds’ retaining $7.7 billion in tax money, as of 

March 1987, related to earnings not recorded in SSA records. 

During 197884, SSA recorded about $58.5 billion less in employees’ earnings than IRS. Although this represents only about 0.8 percent of all 

earnings that SSA recorded during this period and seems relatively small, 

the impact on those affected by uncredited earnings can be significant. 

To insure the timely reconciliation of differences between the two agencies in employer-reported earnings, this report (1) included recommendations to the Secretaries of the Treasury and HHS and (2) suggested 

several matters for the Congress to consider. 

Veterans’ Benefits: 

Improving the 

Integrity of VA’s 

Unedployability 

Comjjensation 

VA pays basic compensation benefits to veterans disabled by injuries or 

disease that were suffered or aggravated while on active military duty. 

Basic benefits can be increased if VA determines that the veteran is 

unemployable due to the service-connected disability. VA generally 

requires veterans to report their annual earnings because those with 

earnings above marginal amounts are not eligible for unemployability 

benefits. 

Progrkm (GAO/HRD87-62, Sept. 21, 1987)* GAO matched SSA'S earned income file and VA'S unemployability file to 

determine how access to tax information could help VA determine the 

extent of a veteran’s earnings. GAO found (1) based on SSA’S earned 

income files, over 90 percent of the veterans who should have reported 

their earnings to VA failed to do so, and (2) access to SW’S files would 

enable VA to identify those veterans not reporting their earnings as 

required. 

GAO also found that VA does not routinely obtain all medical and vocational information needed to determine a veteran’s ability to engage in a 

Page 31 GAO/HRD89-42 GAO Aging Activities in Fiscal Year 1987 
Appendix I 

GAO Reports Relating to Issues Affecting the 

Elderly Issued From October 1,1986, Through 

September 30,1987 

substantially gainful occupation. As a result, GAO believes VA does not 

always have an adequate basis for awarding or denying a veteran’s 

claim for unemployability benefits. 

endment Would 

void Adverse Effects 

eneficiaries (GAO/ 

1 

i 

RD-87-135, Sept. 28, 

1987)* 

Section 9319 of the Omnibus Budget Reconciliation Act of 1986, effective January 1, 1987, amended Medicare law to require certain 

employer-sponsored group health insurers that cover disabled beneficiaries to pay the medical claims of such beneficiaries ahead of Medicare. A disagreement has arisen about whether this law applies to 

health plans sponsored by government employers. 

GAO concluded that until this issue is resolved, disabled beneficiaries 

who have health coverage under Medicare and a government-sponsored 

plan can be faced with a situation in which neither will pay for services. 

Also, unless the law applies to government-sponsored plans, a portion of 

the Medicare savings that were projected when the law was passed will 

not be realized. 

GAO believes that the Congress should amend the Social Security Act so 

that there can be no doubt that this provision applies to governmentsponsored plans. This would eliminate the controversy and make the 

law consistent with similar provisions for other Medicare beneficiaries 

who are covered by government-sponsored health plans. 

Page 32 GAO/HRD88-42 GAO Aging Activities in Fiscal Year 1987 
Appendijr II 

GAO Audits in Process Relating to Issues 

Affecting the Elderly 

VA Health Care: Assuring Quality Care for Veterans in Community and 

State Nursing Homes* 

Review of Appropriateness and Impact of Medicare Fee Schedules for 

Laboratory Services 

HCFA'S Ongoing Efforts to Assure the Appropriateness of Medicare’s 

Diagnosis Related Group Payment Rates 

Survey of Medicare Payments for Services Provided by Health Maintenance Organizations 

Study of Variations in Medicare Payments to Teaching and Nonteaching 

Hospitals 

Employers Not Covered Under Employer Health Insurance Programs* 

Review of Medicare Carriers’ Utilization Review Activities* 

Review of HCFA Evaluation of Peer Review Organizations for Contract 

Renewal* 

Survey of Costs and Use of Contracts with Noncertified Nursing Agencies to Provide Medicare Home Health Services* 

Medicaid Fraud in the Dispensing of Controlled Substances 

Impact of Applying Home Health Cost Limits by Discipline 

Survey of Medicare and Secondary Payer Program for Disabled 

Beneficiaries 

Adequacy of Intermediaries’ and Carriers’ Services to Medicare Beneficiaries and Providers 

Survey of Contractors’ Performance Under the Tri-State Fixed-Price 

Contracts for Medicare Part B* 

Evaluation of Medicare Hospice Program 

Review of Physician Incentive Plans Used by Health Maintenance Organizations With Medicare Risk Contracts* 

Page 33 GAO/HID-8842 GAO Aging Activities in Fiscal Year 1987 
GAO Auditm in I+mctm slelnting to Issues 

AfWeting the Elderly 

Analysis of Medicare’s Proposal to Contract With Employer-Based 

Plans* 

Review of Hospital Indemnity and Specified Disease Insurance* 

Evaluation of Medicare Part B Secondary Payer Program 

Review of HealthChoices Marketing Activities Under Demonstration 

Contract With IICFA* 

Survey of IICFA Management of Medicare Peer Review Organization 

Program* 

Survey of Administration of Medicare’s Tax Equity #and Fiscal Responsibility Act Health Maintenance Organization Program* 

Survey of Transfer of Medicare Patients to VA Hospitals 

Analysis of HCFA'S Health Maintenance Organization Activities* 

Follow-up Review of the Effect of Federal Cost Containment Efforts on 

Medicare and Medicaid Programs 

Assessment of Timeliness of Medicare Claims Payments for Deceased 

Beneficiaries 

Evaluation of Quality of Service Under Medicare Program 

Assistance to Senate Aging Committee in Determining Reasons for the 

Large Medicare Part B Premium Increases for 1987* ’ I, 

Effect of Prospective Payment System on the Closing of Rural Hospitals 

Monitoring and Evaluating the Implementation of P h iladelphia’s Medicaid Health Insuring Organization (HealthPass)* 

Review of Transfer of Assets for Persons to Become IEligible for Medicaid Nursing Home Care 

Review of Application of Residents’ Income to Offset Medical Costs in 

Nursing Homes 

Page 24 GAO/HRD88-42 GAO Aging Activities in Fiscal Year 1987 
Appendix II 

GAO Audits in Process Relating to Issues 

Affecting the Elderly 

Survey of Benefits and Protections to Private Long-Term Care Insurance 

Policyholders* 

Survey of Adequacy of Access to Nursing Homes for Medicaid 

Beneficiaries* 

Review of Medicaid Nursing Home Residents’ Savings Bond Holdings 

Pension Plans: Possible Effects of Requiring Employers to Make Contributions Sooner* 

How Can the Integrity of the Social Security Card Be Improved?* 

Survey for Follow-up to the SSA Management Review 

Survey of Alternatives for Nursing Home Residents Capable of Residing 

Outside Institutional Settings* 

%A Service Quality* 

Evaluation of SSA Samples to Determine Retirement and Survivors’ 

Insurance Payment Accuracy 

Review of Railroad Retirement Board Administration of Certain Benefit 

Offset Provisions* 

What Is the Impact of the Social Security Retirement Test? 

Review of the Solvency of the Railroad Retirement Board Trust Funds* 

Survey to Determine the Extent to Which SSA Accurately Maintains 

Social Security Earnings Records 

Effects of Budget Constraints on SSA Disability Adjudication* 

Role of Vocational Rehabilitation in the Social Security Disabled 

Program* 

Development of Demographic Data on Various Groups of Disabled 

Persons* 

Evaluation of SSA’S Face-to-Face Demonstration* 

Page 35 GAO/HRD83-42 GAO Agiug Activities in Fiscal Year 1987 
Appendix II 

GAO Audits in Process Relating to Issues 

Affecting the Elderly 

Block Grants: Federal Set-Aside Provisions for Substance Abuse and 

Mental Health* 

An Evaluation of HCFA'S Collection, Interpretation, and Use of Mortality 

and Morbidity Outcome Data on Medicare Beneficiaries* 

Modeling Factors Associated with the Effectiveness of Quality Assessment by Medicare Peer Review Organizations* 

Simulating the Effectiveness of Alternative Medical Peer Review Quality 

Assurance Methods* 

Alternative Ways of Looking at the Financial Position of the Social 

Security Trust Fund4 

Strategies for Measuring and Monitoring the Quality of Care in the Medicare Program* 

‘Being performed at the request of Committees or Members of Congress. 

Page 36 GAO/HRD-83-42 GAO Aging Activities in Piscal Yeax 1987 
Appendix III 

GAO Activities Affecting Older Persons 

During fiscal year 1987, GAO appointed 963 persons to permanent and 

temporary positions, of whom 112 were age 40 and older. As of September 30, 1987, GAO'S work force totaled 5,786; 2,598 (44.9 percent) were 

40 and older. 

GAO employment policies prohibit discrimination based on age. GAO'S 

Civil Rights Office continues to provide information and advice to persons regarding allegations of age discrimination. 

GAO continues to provide individual retirement counseling and preretirement seminars for employees nearing retirement age. The counseling 

and seminars are intended to assist employees in 

calculating retirement income available through the Civil Service and 

Social Security systems and understanding options involving age, grade, 

and years of service; 

understanding health insurance and survivor benefit plans; 

acquiring information helpful in planning a realistic budget based on 

income, tax obligations, and benefits, and making decisions concerning 

legal matters; 

gaining insights and perspectives concerning adjustments to retirement; 

increasing awareness of community resources that deal with preretirement planning, second career opportunities, and financial planning; and 

increasing awareness of lifestyle options available during the transition 

from work to retirement. 

*U.S. 

9’ 

P.O. 1987-201-749160211 

(118219) Page 37 GAO/HR.D-88-42 GAO Aging Activities in Fiscal Year 1987 

, 
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