End-of-Life Care
Key Components Provided by Programs in Four States Gao ID: GAO-08-66 December 14, 2007Approximately 28 percent of all Medicare spending in 1999 was used to provide care for beneficiaries in the last year of their lives. The Medicare hospice benefit is specifically designed for end-of-life care but is an elected benefit for individuals who have a terminal diagnosis with a prognosis of 6 months or less if the disease runs its normal course. GAO was asked to identify examples of programs that provide key components of end-of-life care. Specifically, GAO (1) identified key components of end-of-life care, (2) identified and described how certain programs incorporate key components of end-of-life care, and (3) described the challenges program providers have identified to delivering the key components of end-of-life care. To identify the key components of end-of-life care, GAO relied on studies by the Institute of Medicine (IOM) and the Agency for Healthcare Research and Quality (AHRQ). To identify and describe programs that implement these key components and describe the challenges providers of these programs face, GAO conducted site visits to four states, Arizona, Florida, Oregon, and Wisconsin, that, in addition to other criteria, demonstrated a high use of end-of-life services. We interviewed officials of federal, state, and private programs in these four states that provide care to individuals nearing the end of life.
The IOM and AHRQ studies identified the following key components in providing care to individuals nearing the end of life: care management to coordinate and facilitate service delivery; supportive services, such as transportation, provided to individuals residing in noninstitutional settings; pain and symptom management; family and caregiver support such as respite care; communication among the individuals, families, and program staff; and assistance with advance care planning to aid individuals with making decisions about their future care. The programs GAO identified in the four states incorporate key components of end-of-life care when delivering services to individuals nearing the end of life. These programs use care management, either through a case manager or an interdisciplinary care team of health care professionals, to ensure continuity of care and the delivery of appropriate services. The programs also provide supportive services, such as personal care services or meal delivery, to assist individuals in their homes. Pain and symptom management is provided by these programs to treat pain and other symptoms of an individual who is seriously ill. These programs provide family and caregiver support through services that alleviate demands on the caregiver and by providing bereavement support for family members. The programs foster communication with individuals and family members to plan care that reflects each individual's choices. In addition, these programs use tools such as electronic medical records to facilitate communication among staff members. The programs GAO identified initiate and encourage advance care planning for the end of life and assist individuals with making decisions about future medical care, such as completing advance directives and identifying health care proxies, that is, those who can make health care decisions on behalf of the individual. Providers of the programs GAO identified described challenges they encounter to delivering some of the key components of end-of-life care. Providers described difficulties delivering supportive services and family and caregiver supports to rural residents because of travel distances, fewer community-based service options, and an inability to hire adequate numbers of staff in rural areas. Providers also stated that, in their experience, physician training and practices can inhibit the provision of pain and symptom management and advance care planning to individuals nearing the end of life. A recent article published in a medical journal GAO reviewed identified similar issues with physician training and practices. The Centers for Medicare & Medicaid Services (CMS), the agency that administers Medicare and Medicaid, commented that the report is a useful description of diverse provider types that deliver services to persons coming to the end of life. CMS noted that the report is especially helpful as a time approaches when more Americans will be living with serious and eventually fatal chronic conditions.
GAO-08-66, End-of-Life Care: Key Components Provided by Programs in Four States
This is the accessible text file for GAO report number GAO-08-66
entitled 'End-Of-Life Care: Key Components Provided by Programs in Four
States' which was released on January 14, 2008.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to the Honorable Ron Wyden, U.S. Senate:
United States Government Accountability Office:
GAO:
December 2007:
End-of-Life Care:
Key Components Provided by Programs in Four States:
End-of-Life Care:
GAO-08-66:
GAO Highlights:
Highlights of GAO-08-66, a report to the Honorable Ron Wyden, U.S.
Senate.
Why GAO Did This Study:
Approximately 28 percent of all Medicare spending in 1999 was used to
provide care for beneficiaries in the last year of their lives. The
Medicare hospice benefit is specifically designed for end-of-life care
but is an elected benefit for individuals who have a terminal diagnosis
with a prognosis of 6 months or less if the disease runs its normal
course. GAO was asked to identify examples of programs that provide key
components of end-of-life care. Specifically, GAO (1) identified key
components of end-of-life care, (2) identified and described how
certain programs incorporate key components of end-of-life care, and
(3) described the challenges program providers have identified to
delivering the key components of end-of-life care. To identify the key
components of end-of-life care, GAO relied on studies by the Institute
of Medicine (IOM) and the Agency for Healthcare Research and Quality
(AHRQ). To identify and describe programs that implement these key
components and describe the challenges providers of these programs
face, GAO conducted site visits to four states, Arizona, Florida,
Oregon, and Wisconsin, that, in addition to other criteria,
demonstrated a high use of end-of-life services. We interviewed
officials of federal, state, and private programs in these four states
that provide care to individuals nearing the end of life.
What GAO Found:
The IOM and AHRQ studies identified the following key components in
providing care to individuals nearing the end of life: care management
to coordinate and facilitate service delivery; supportive services,
such as transportation, provided to individuals residing in
noninstitutional settings; pain and symptom management; family and
caregiver support such as respite care; communication among the
individuals, families, and program staff; and assistance with advance
care planning to aid individuals with making decisions about their
future care.
The programs GAO identified in the four states incorporate key
components of end-of-life care when delivering services to individuals
nearing the end of life. These programs use care management, either
through a case manager or an interdisciplinary care team of health care
professionals, to ensure continuity of care and the delivery of
appropriate services. The programs also provide supportive services,
such as personal care services or meal delivery, to assist individuals
in their homes. Pain and symptom management is provided by these
programs to treat pain and other symptoms of an individual who is
seriously ill. These programs provide family and caregiver support
through services that alleviate demands on the caregiver and by
providing bereavement support for family members. The programs foster
communication with individuals and family members to plan care that
reflects each individual‘s choices. In addition, these programs use
tools such as electronic medical records to facilitate communication
among staff members. The programs GAO identified initiate and encourage
advance care planning for the end of life and assist individuals with
making decisions about future medical care, such as completing advance
directives and identifying health care proxies, that is, those who can
make health care decisions on behalf of the individual.
Providers of the programs GAO identified described challenges they
encounter to delivering some of the key components of end-of-life care.
Providers described difficulties delivering supportive services and
family and caregiver supports to rural residents because of travel
distances, fewer community-based service options, and an inability to
hire adequate numbers of staff in rural areas. Providers also stated
that, in their experience, physician training and practices can inhibit
the provision of pain and symptom management and advance care planning
to individuals nearing the end of life. A recent article published in a
medical journal GAO reviewed identified similar issues with physician
training and practices.
The Centers for Medicare & Medicaid Services (CMS), the agency that
administers Medicare and Medicaid, commented that the report is a
useful description of diverse provider types that deliver services to
persons coming to the end of life. CMS noted that the report is
especially helpful as a time approaches when more Americans will be
living with serious and eventually fatal chronic conditions.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.GAO-08-66]. For more information, contact
Kathleen King at (202) 512-7114 or kingk@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Key Components of End-of-Life Care:
Programs Incorporate Key Components of End-of-Life Care:
Providers Find Challenges to Delivering Certain Key Components of End-
of-Life Care:
Agency Comments and Our Evaluation:
Appendix I: Comments from the Centers for Medicare & Medicaid Services:
Appendix II: GAO Contact and Staff Acknowledgments:
Abbreviations:
ABMS: American Board of Medical Specialties:
AHRQ: Agency for Healthcare Research and Quality:
ALTCS: Arizona Long Term Care System:
CMS: Centers for Medicare & Medicaid Services:
COPD: chronic obstructive pulmonary disease:
IOM: Institute of Medicine:
NAHC: National Association for Home Care and Hospice:
NEJM: New England Journal of Medicine:
NHPCO: National Hospice and Palliative Care Organization:
PACE: Program of All-Inclusive Care for the Elderly:
POLST: Physician Orders for Life-Sustaining Treatment:
WPP: Wisconsin Partnership Program:
United States Government Accountability Office:
Washington, DC 20548:
December 14, 2007:
The Honorable Ron Wyden:
United States Senate:
Dear Senator Wyden:
In 1999, approximately 28 percent of all Medicare spending was used to
provide care for beneficiaries in the last year of their
lives.[Footnote 1] A large percentage of this spending was for
institutional services such as hospital inpatient or nursing home care;
for example, slightly more than 58 percent of this spending was for
hospital inpatient services. In that same year, approximately 1.5
million individuals over age 65 resided in nursing homes. Sixty-two
percent of these individuals had their nursing home care paid for by
Medicaid and about 16 percent had their care paid for by
Medicare.[Footnote 2],[Footnote 3] However, there are alternatives to
institution-based end-of-life care, such as home and community-based
services. In 2005, the Administrator of the Centers for Medicare &
Medicaid Services (CMS), the federal agency that administers Medicare
and Medicaid, testified that providing home and community-based
services, such as personal care services,[Footnote 4] can be a cost-
effective way to provide end-of-life care while increasing personal
autonomy and allowing individuals to live in their homes, surrounded by
friends and family.[Footnote 5]
Advances in treating diseases have lengthened the life expectancy of
Americans, and chronic conditions such as heart failure, diabetes, or
kidney failure are no longer immediately fatal and can be treated or
managed with medication. As a result, more than 80 percent of Americans
lived past age 65 in 2000; however, many individuals live their last
years of life with chronic conditions. For example, according to the
2003 Medicare Current Beneficiary Survey, 21 percent of beneficiaries
have had a diagnosis of diabetes, 5 percent have had a diagnosis of
Alzheimer's disease, and 15 percent have had a diagnosis of pulmonary
disease, such as chronic obstructive pulmonary disease (COPD). In
addition, 73 percent of beneficiaries reported that they had two or
more chronic conditions. Medicare beneficiaries with chronic health
conditions use many health care resources. Ninety percent of Medicare
beneficiaries over age 65 live with a chronic condition in the year
before death.
Medicare has a program that is specifically designed for end-of-life
care, the hospice benefit. The hospice benefit is designed to provide
comfort and pain relief and emotional and spiritual support to
individuals with a terminal illness, generally in a home setting.
Medicare hospice services include, for example, nursing care,
counseling, and homemaker services, as well as drugs and medical
supplies. However, not all individuals nearing the end of life may
qualify for or elect to receive care under this benefit. To be eligible
for the benefit, a physician must certify an individual as having a
life expectancy of 6 months or less if his or her illness runs its
normal course. Physicians certifying patients for hospice are expected
to use their best clinical judgment regarding the normal course of the
individual's illness. However, the course of many conditions, such as
COPD, is often uncertain, making it difficult for physicians to predict
accurately the life expectancy of individuals with these conditions
and, therefore, refer them to hospice. In addition, a beneficiary who
elects hospice must waive Medicare coverage for curative care related
to the terminal illness for the period the election is in
effect.[Footnote 6] Some individuals are reluctant to forgo curative
care for their terminal illness and, therefore, do not elect hospice.
You are interested in health care services delivered to individuals who
are nearing the end of life and asked us to identify examples of
programs, other than hospice, that provide key components of end-of-
life care. In this report, we (1) identify key components of end-of-
life care, (2) identify and describe how certain programs incorporate
key components of end-of-life care, and (3) describe the challenges
program providers have identified to delivering the key components of
end-of-life care.
To identify key components of end-of-life care, we interviewed
officials from CMS and 10 national independent and academic researchers
in end-of-life and long-term care. In addition, we interviewed
officials from the National Hospice and Palliative Care Organization
(NHPCO) and the National Association for Home Care and Hospice (NAHC),
industry organizations that represent home care agencies, hospices, and
palliative care providers. Based on these interviews, we identified and
relied primarily on two extensive studies to identify the key
components of end-of-life care: a 1997 Institute of Medicine (IOM)
study and a 2004 study published by the Agency for Healthcare Research
and Quality (AHRQ).[Footnote 7],[Footnote 8] The IOM study identified
factors that promote high-quality care for individuals near the end of
life. The report was prepared by an IOM-appointed committee that
included health care professionals and researchers with expertise in
geriatrics, end-of-life care, chronic illness and disability, pain
management, and long-term care. The committee prepared this report with
the objective of stimulating discussion, encouraging consensus on how
care for those approaching death can be improved, and encouraging
action to implement that consensus. The AHRQ report is a study on the
state of the science regarding end-of-life care. It includes a
comprehensive review of the literature that addresses the effectiveness
of specific health care interventions for improving outcomes in
individuals at the end of life. In preparing its report, AHRQ reviewed
a total of 5,165 abstracts applicable to the report's key questions
that were published in the English language, appeared in journals from
1990 through 2004, involved human subjects, and did not include
individual case reports. The AHRQ report was peer reviewed by a
multidisciplinary technical expert panel that included leading
scientists and clinicians in nursing, gerontology, and palliative
medicine and others with a broad knowledge of relevant research and
policy issues.
To identify the programs that deliver key components of end-of-life
care and describe how they incorporate these key components, we first
interviewed the officials from CMS, NHPCO, and NAHC and the 10 national
independent and academic researchers in end-of-life and long-term care.
We also used 2001 data from the U.S. Census Bureau to identify states
that had a high percentage of population age 65 and over. We reviewed
2003 data from the National Center for Health Care Statistics and 2000
through 2003 data from The Dartmouth Atlas of Health Care to identify
states that had low health care service utilization as a proxy for
higher-than-average use of care management.[Footnote 9] In addition, we
examined fiscal year 2004 Medicaid data on states' spending for certain
home and community-based services. We reviewed data on the utilization
of Medicare hospice services at the end of life from a study published
in 2002 as a proxy for individuals who use noninstitutional services
for end-of-life care. Using information from our interviews and these
data, we identified 14 states that meet at least one of the following
criteria: a high proportion of individuals over age 65, low health care
service utilization, a high proportion of Medicaid spending for home
and community-based services relative to spending for institutional
services, or a high proportion of individuals who use hospice services
at the end of life. From the 14 states we identified, we selected 4
states, Arizona, Florida, Oregon, and Wisconsin, that are
geographically diverse and have at least one state or local program
that provides care to individuals nearing the end of life. We
identified programs in these states that provide care to individuals
nearing the end of life and interviewed representatives of providers of
these programs: the Program of All-Inclusive Care for the Elderly
(PACE), the Wisconsin Partnership Program (WPP), the Medicaid Arizona
Long Term Care System (ALTCS), and palliative care programs. To
describe how these programs incorporate key components of end-of-life
care, we conducted site visits to interview representatives of PACE
providers in Florida, Oregon, and Wisconsin; representatives of three
providers of WPP;[Footnote 10] state officials from the ALTCS program;
and representatives of at least 2 palliative care programs in each of
the four states for a total of 12 palliative care programs.[Footnote
11]
To describe the challenges these programs encounter in providing the
key components of end-of-life care, we conducted site visits to
interview representatives of PACE providers in Florida, Oregon, and
Wisconsin; representatives of three providers of WPP; state officials
from the ALTCS program; and representatives of at least 2 palliative
care programs in each of the four states for a total of 12 palliative
care programs. We performed our work from June 2005 through August 2007
in accordance with generally accepted government auditing standards.
Results in Brief:
The IOM and AHRQ studies identified six key components in providing
care at the end of life. These were care management to coordinate and
facilitate service delivery; supportive services to assist individuals
residing in noninstitutional settings; pain and symptom management;
family and caregiver support; communication among the individuals,
families, and program staff; and assistance with advance care planning
to aid individuals with making decisions about their future care.
The programs we identified in four states that incorporate these key
components of end-of-life care when delivering services to individuals
nearing the end of life are PACE, WPP, ALTCS, and palliative care
programs. These programs use care management, either through a case
manager or an interdisciplinary care team of providers, to ensure
continuity of care and the delivery of appropriate services; supportive
services such as personal care services to assist individuals with
daily activities or transportation to access medical care; pain and
symptom management to improve quality of life and assist with
transitions at the end of life; family and caregiver support through
services that alleviate demands on the caregiver and provide
bereavement support; communication to assist individuals and their
families with developing care plans that reflect their choices; and
advance care planning to assist individuals with decision making at the
end of life.
Providers we interviewed in the four states found challenges to
delivering some key components of end-of-life care. Representatives of
the providers described difficulties providing supportive services and
family and caregiver support to rural residents because of travel
distances, fewer community-based service options, and an inability to
hire adequate numbers of staff in rural areas. Provider representatives
also stated that, in their experience, physician training and practices
can inhibit the provision of pain and symptom management and advance
care planning to individuals nearing the end of life. A recent article
published in a medical journal we reviewed identified similar issues
with physician training and practices.
In commenting on a draft of this report, CMS stated that the report is
a useful description of a diverse set of provider types in very
different settings providing services to persons coming to the end of
life, and is especially helpful as a time approaches when more
Americans will be living with serious and eventually fatal chronic
conditions. CMS noted that it was useful that our report included
individuals living with serious chronic conditions who might live for
some years.
Background:
PACE integrates Medicare and Medicaid financing to provide
comprehensive delivery of those programs' services to individuals age
55 and older who have been certified as eligible for nursing home care
by a state under Medicaid. PACE providers are, or are a separate part
of, government entities or are not-for-profit private or public
entities that provide PACE services to eligible individuals. PACE
services include, but are not limited to, all Medicare services and all
Medicaid services as specified in the state plan.[Footnote 12] Adult
day care, medical treatment, home health and personal care,
prescription drugs, social services, restorative therapies, respite
care,[Footnote 13] and hospital and nursing home care when necessary
are all required services under PACE. For most individuals, the
comprehensive services offered by PACE allow them to live in their
homes. CMS requires that each PACE provider operate an adult day center
for its beneficiaries.
WPP is a state-sponsored program that integrates Medicare and Medicaid
financing to provide comprehensive delivery of those programs' services
to individuals age 55 and older and individuals age 18 and older with
physical disabilities who have been certified by Wisconsin as eligible
for nursing home care. To deliver WPP services, the state contracts
with organizations to provide eligible individuals with primary, acute,
and long-term care services; prescription drugs; rehabilitation
services and physical therapy; adult day care; nursing home care;
durable medical equipment and supplies; and other services such as meal
delivery and transportation to medical appointments. The comprehensive
services provided by WPP are intended to allow individuals to live in
the setting of their choice. While similar to PACE, WPP does not
require that providers operate an adult day center.
ALTCS, the long-term care division of the Arizona Medicaid program,
serves individuals who are age 65 and over, blind, or disabled and who
need ongoing services at a nursing home level of care. Arizona provides
all its Medicaid services through a Medicaid waiver, which allows some
flexibility in the design and administration of the program.[Footnote
14] In Arizona, ALTCS contracts with providers to deliver acute medical
care services, institutional care, hospice, behavioral health services,
home health, homemaker services, personal care, respite care,
transportation, adult day care, and home delivered meals. Many ALTCS
participants are able to live in their own homes or in assisted living
facility and receive in-home services.
Palliative care programs are operated by a variety of health care
entities, including hospitals, health care systems, and hospices. These
programs generally do not receive federal or state funding and may rely
on private grants or charitable support. Palliative care programs are
designed to improve the quality of a seriously ill individual's life
and support the individual and his or her family during and after
treatment. Services provided by palliative care programs vary and may
include pain and symptom management, assistance with planning for
additional services, and psychosocial and spiritual support and can be
provided in conjunction with curative care.
Key Components of End-of-Life Care:
The IOM and AHRQ studies identified the following key components in
providing care to individuals nearing the end of life: care management;
supportive services for individuals; pain and symptom management;
family and caregiver support; communication among the individuals,
families, and program staff; and assistance with advance care planning.
Care management, also referred to as case management, interdisciplinary
care, or care coordination, is the coordination and facilitation of
service delivery and can be provided by a team or a single manager.
Supportive services include personal care services, home delivered
meals, transportation to medical appointments, and other services that
assist individuals who reside in noninstitutional settings. Pain and
symptom management is pharmacological and nonpharmacological therapies,
such as massage therapy, to treat pain and other symptoms of an
individual who is seriously ill. Family and caregiver support are
services that provide assistance to those caring for an individual
nearing the end of life in his or her home and can include respite care
and bereavement counseling. Communication among individuals, families,
and program staff includes discussions regarding end-of-life issues
with individuals and their family members and the use of various tools
to foster communication among program staff. Advance care planning is
the process by which individuals make decisions about their future care
and may include the completion of written documents, such as advance
directives.[Footnote 15]
Specifically, IOM reported that for individuals nearing the end of
life, care systems should ensure that the following are provided:
interdisciplinary care management; home care or personal care services,
which we refer to as supportive services; pain and symptom management;
supportive care for caregivers and family through services such as
respite care or housekeeping services; and communication. The IOM
report also identified advance care planning as a key component of end-
of-life care. The IOM report recommended that people nearing the end of
life should receive supportive services managed by those involved in
their care and that health care organizations should facilitate advance
care planning. In addition, the IOM report recommended that health care
professionals improve care for individuals nearing the end of life by
providing pain and symptom management.
The AHRQ report focused on identifying outcomes that can indicate the
quality of the end-of-life experience and identifying the patient,
family, and health care system factors that are associated with better
or worse outcomes at the end of life. The AHRQ report identified
continuity of health care, such as that provided through care
management; supportive services, such as home care services; pain and
symptom management; support for families and caregivers; and effective
communication among program staff, which could include improved medical
record documentation, as core components of end-of-life care.
The programs we identified in four states that incorporate key
components of end-of-life care described in the IOM and AHRQ reports
are PACE, WPP, ALTCS, and palliative care programs. These programs use
care management to ensure continuity of care and supportive services,
such as personal care services, to assist individuals nearing the end
of life. These programs also integrate pain and symptom management into
their services; provide family and caregiver support; foster
communication among the individuals, families, and program staff; and
initiate or encourage advance care planning.
Programs Use Care Management to Ensure Continuity of Care:
Care management is used by all of the programs we identified to ensure
continuity of care for individuals nearing the end of life. Most of
these programs provide care management through interdisciplinary care
teams. The interdisciplinary care teams of PACE providers include a
primary care physician, nurse, social worker, physical therapist,
occupational therapist, recreational therapist or activity coordinator,
dietitian, PACE adult day center manager, health care aides, and
transportation providers. PACE beneficiaries attend a PACE adult day
center where they receive services from the interdisciplinary care
team. The WPP providers use an interdisciplinary care team approach
similar to PACE, although the teams are generally smaller.
Representatives of two WPP providers we interviewed stated that care
management reduces hospitalizations. Representatives of one of these
providers stated that care management ensures that individuals admitted
to a hospital are discharged to an appropriate setting to avoid
unnecessary readmission. Representatives of the second WPP provider
stated that care management improves the medical care of individuals by
providing physicians with an accurate picture of individuals' health
status and assisting individuals with accessing physicians in a timely
manner. Representatives of both PACE and WPP providers stated that the
interdisciplinary care teams meet to exchange information, ensure that
individuals' needs are being met, and address changes in the health
status of individuals.
The four hospital-based palliative care programs we identified use
interdisciplinary care teams to coordinate services. These programs'
teams include medical directors, social workers, chaplains, nurses,
psychologists, and case managers. Two of the hospice-based palliative
care programs developed partnerships with local hospitals and use
interdisciplinary care teams to assist individuals. Two other hospice-
based palliative care programs use interdisciplinary care teams of
health care professionals to coordinate medical, nursing, social work,
and spiritual services. Staff from one of these programs told us that
because case managers facilitate communication among different medical
providers and ensure that tests performed have a clear purpose,
unnecessary or duplicate tests are avoided. One hospice-based
palliative care program's interdisciplinary care team consists of a
nurse, social worker, and palliative care physician who coordinate care
and monitor the quality of care provided. The two palliative care
programs operated by health care systems use interdisciplinary care
teams composed of nurses, social workers, chaplains, and pharmacists.
The care team of one of these palliative care programs makes treatment
recommendations and enhances coordination among medical staff. The
other of these palliative care programs provides social and
psychological support and assists individuals with transitioning
between the hospital and their homes. One hospice-based palliative care
program uses a single case manager to assist individuals with
coordinating services.
In the ALTCS program, each Medicaid beneficiary is assigned a case
manager. The case manager aids the beneficiary in obtaining necessary
services, coordinates service delivery, and consults with other
providers as needed. ALTCS case managers refer beneficiaries to other
social service agencies when additional services are needed. ALTCS
officials noted that a unique feature of the program is that it
provides institutional, supportive, and all other medical and long-term
care services under one agency and under the supervision of a single
case manager for each beneficiary. An official also noted that the
ALTCS program fosters continuity of care and care coordination at the
end of life through the case manager and the integrated delivery of
services from a single agency.
Programs Use Supportive Services:
The programs we identified provide a variety of supportive services to
assist individuals near the end of life. The PACE providers we
interviewed are required to deliver supportive services such as
personal care services, adult day care, social work services, and meal
delivery. Representatives of one PACE provider stated that one strength
of PACE is the integration of all Medicare-and Medicaid-covered
services, which includes the supportive services, such as personal care
services, covered by Medicaid. Representatives of a PACE provider
reported that when individuals become too frail to come to the day
center, a designated team visits individuals in their homes to provide
personal care, nursing, and physician services. Representatives of this
provider also described how they assist individuals residing in
residential care facilities and adult foster homes who are nearing the
end of life by providing additional staff support and visits from the
primary care physician.
The supportive services offered by WPP providers include social
services, personal care services, adult day care, environmental
adaptations,[Footnote 16] meal delivery, and transportation to medical
appointments. Representatives of a WPP provider stated that they also
involve local community resources such as religious institutions and
friends to ensure that individuals receive the assistance they need in
their homes and communities. Representatives of another WPP provider
stated that the most common supportive services they provide are home
care, transportation, and day center activities. Representatives of
this provider noted that as individuals get closer to the end of life,
additional home care support can be provided.
Supportive services provided by the ALTCS program include home health
services, homemaker services, personal care, transportation, adult day
care, and home delivered meals. ALTCS officials stated that the type of
supportive services provided can vary significantly depending on a
beneficiary's level of functioning and the level of support provided by
the family. A CMS official noted that two-thirds of ALTCS beneficiaries
receive supportive services in their homes or communities, which the
official cited as being above the national average.
The palliative care programs we identified either provide supportive
services directly to individuals nearing the end of life or assist
individuals with obtaining such services. One hospice-based palliative
care program provides individuals telephone calls and visits and
assists individuals with applying for other benefits. Another hospice-
based palliative care program provides supportive care that includes
nursing and social work services and spiritual counseling. A palliative
care program that is operated by a health care system provides
individuals with 24-hour nursing support and pastoral services. A
palliative care program operated by a hospital helps individuals
establish supportive services, such as personal care services, at the
time of discharge from the hospital.
Programs Provide Pain and Symptom Management:
All the programs we identified provide pain and symptom management or
assist with the coordination of such services. Representatives of the
WPP and PACE providers we interviewed incorporate pain and symptom
management into the care they provide. For example, representatives of
a provider of both PACE and WPP described how individuals they serve
are able to receive pain and symptom management services whenever they
feel such services are necessary. One PACE provider we interviewed
offers pain and symptom management to individuals nearing the end of
life, and a palliative care team visits individuals in the home when
they are unable to attend the PACE day center. Other providers of PACE
and WPP obtain assistance from local hospices to help provide pain and
symptom management services, such as overnight nursing, spiritual care,
or pain management. ALTCS provides pain and symptom management to
individuals when such services are needed. Representatives of the 12
palliative care providers we interviewed provide or assist with
coordinating pain and symptom management for individuals in either the
home or hospital setting.
Programs Offer Family and Caregiver Support:
Programs we identified offer family and caregiver support through a
variety of services. PACE and WPP providers offer family and caregiver
support through personal care services, which can help alleviate
demands on a caregiver, and respite services provided in the home. In
addition, the adult day centers operated by the PACE providers we
visited offer respite opportunities for the caregivers of the
individuals who attend the day care programs. One WPP provider also
operates a day center to provide caregivers with respite. The ALTCS
program provides support for caregivers through personal care, respite,
and adult day care services.
Most of the palliative care programs we identified also provide support
to family members and caregivers. They provide this support in a
variety of ways. Two hospice-based palliative care programs use social
workers to assist families and caregivers with end-of-life decision
making and accessing community agencies and resources. Another hospice-
based palliative care program uses an interdisciplinary care team to
assist families in making end-of-life decisions. One hospital-based
palliative care program, two hospice-based palliative care programs,
and one palliative care program operated by a health care system
provide bereavement support to family members. One health care system's
palliative care program provides 24-hour nursing support for
individuals in their homes, which assists caregivers, and another
palliative care program operated by a hospice assists family members
with coordinating in-home support services. Two hospital-based
palliative care programs assist families with coordinating care upon an
individual's discharge from the hospital. Officials from one hospice-
based palliative care program and a palliative care program operated by
a hospital both stated that they provide education about end-of-life
care to family members.
Programs Foster Communication among the Individuals, Families, and
Program Staff:
The programs we identified communicate frequently with individuals and
their families regarding end-of-life issues. Representatives of the
PACE, WPP, and palliative care providers and ALTCS officials we
interviewed stated that they work with individuals and their families
to develop a plan of care that reflects each individual's choices. For
example, a representative of a PACE provider described how the
interdisciplinary care team fosters communication with the individual
about what type of care he or she wants to receive at the end of life,
including pain and symptom management. Representatives of a provider of
both PACE and WPP described how the interdisciplinary care team
establishes goals with the individual and includes a physician and
social worker to facilitate discussions involving end-of-life issues. A
hospital-based palliative care program's interdisciplinary care team
holds meetings with family members to discuss an individual's health
status, prognosis, and end-of-life wishes, and another palliative care
program has discharge coordinators follow up with individuals for as
long as services are required. An ALTCS official stated that case
managers discuss with beneficiaries what their needs are and what care
they want to receive. Representatives of palliative care, PACE, and WPP
providers informed us that they develop close, trusting relationships
with individuals through their frequent communication to facilitate
discussions about end-of-life care.
Representatives of PACE, WPP, and palliative care providers we
interviewed stated that communicating with individuals and their
families about end-of-life issues earlier, rather than later, in the
individual's illness makes it easier for both the individual and family
to manage the decisions they face when the individual is closer to
death. Representatives of a WPP provider stated that they have
continuous conversations with individuals and families about plans for
the end of life, and representatives of a PACE provider noted that they
have these discussions early because such discussions become more
challenging when someone is very near the end of life. Representatives
of another WPP provider stated that they have monthly conversations
with individuals about which life-saving measures they would like
implemented as their condition worsens. A PACE provider's staff visits
an individual nearing the end of life every other day to ensure that
the individual's and family's needs are being met. Representatives of a
palliative care provider described how they repeatedly discuss with
individuals near the end of life the availability of other services
such as hospice.
Programs we identified use a variety of tools to foster communication
among the members of the care team concerning individuals' needs as
they near the end of life. Staff members of a provider of both PACE and
WPP use a checklist to identify changes in an individual's condition.
The checklist is completed at an individual's periodic review or
whenever there is a change in health status and helps inform the care
team about the need to discuss end-of-life planning with the
individual. Representatives of providers described the benefits of
electronic medical records in promoting communication among members of
the care team. Representatives of a PACE provider and a palliative care
program stated that creating an electronic medical record accessible to
all members of the care team facilitates communication among the team
regarding the condition of each beneficiary and increases the quality
of care. A palliative care provider distributed laptop computers and
handheld wireless devices to all clinical staff. Using these devices,
clinical staff can both access and input information when they visit an
individual's home, which keeps all staff who interact with the
individual informed. Another palliative care provider shares
clinicians' notes and correspondence electronically, which enhances
communication.
Representatives of a hospice-based palliative care provider in Oregon
stated that the physicians they work with are more comfortable
discussing end-of-life issues with their patients since the 1997
enactment in Oregon of the Death with Dignity Act, which focused
attention in the state on end-of-life care and the options available to
individuals. Representatives of a palliative care program operated by a
health care system we interviewed stated that passage of this act
helped create an environment in Oregon where end-of-life issues are
discussed more openly.
Programs Initiate and Encourage Advance Care Planning:
The WPP, PACE, and palliative care providers initiate or encourage
advance care planning to assist individuals with planning for the end
of life, making decisions about future medical care, and sharing
information with family members. Representatives of all the PACE
providers stated that they assist individuals with advance care
planning tasks, such as completing advance directives and identifying
health care proxies, that is, those who can make health care decisions
on behalf of the individuals. Representatives of a provider of PACE and
WPP stated that each individual begins the advance care planning
process as soon as he or she is admitted to the program. This
provider's staff members work with individuals to identify health care
proxies and persuade individuals to communicate their decisions to
family members. Representatives of a WPP provider stated that the staff
have monthly conversations with individuals about their end-of-life
choices, such as do-not-resuscitate orders. Representatives of another
WPP provider stated that the care team encourages individuals and their
families to plan for the end of life, and representatives of a provider
of both PACE and WPP discuss with individuals all the medical services
and interventions they wish to receive.
Officials of palliative care programs stated that they offer assistance
to individuals enrolled in their programs in completing advance
directives and informing their families of any decisions they have made
about their end-of-life care. One palliative care program operated by a
hospice assists individuals with completing advance directives and
informing family members of their decisions for the end of life.
Palliative care programs operated by hospitals assist individuals with
advance care planning tasks such as completing advance directives and
making medical decisions.
Representatives of a PACE provider in Oregon stated that they use
Physician Orders for Life-Sustaining Treatment (POLST) forms to assist
all individuals in their program with advance care planning.[Footnote
17] The POLST form is a physician's order that communicates which
medical interventions should be performed in the event of a health
emergency. Similar to other advance directives, the POLST form allows
individuals to document their choices regarding the use of life-
sustaining procedures; a representative in Oregon stated that, unlike
other advance directives, POLST forms are physician orders, which are
more effective at communicating an individual's preferences to
providers, particularly when the individual is transferred across
health care settings. A representative of an Oregon PACE provider
stated that the POLST form makes an individual's wishes clear and,
because it is in the form of a physician's order, legally protects
medical personnel, including emergency medical technicians, when they
carry out an individual's documented choices during an emergency.
Providers Find Challenges to Delivering Certain Key Components of End-
of-Life Care:
Representatives of providers we interviewed described challenges they
encounter to delivering some of the key components of end-of-life care.
They described difficulties delivering supportive services and family
and caregiver support to rural residents because of travel distances,
fewer community-based service options, and an inability to hire
adequate numbers of staff in rural areas. Representatives of providers
also stated that they believe physician training and practices can
inhibit the provision of pain and symptom management and advance care
planning to individuals nearing the end of life.
Providers Encounter Challenges Delivering Supportive Services and
Family and Caregiver Support to Rural Residents:
Representatives of providers we interviewed described difficulties
delivering supportive services and family and caregiver support to
rural residents because of travel distances, lack of community-based
services, and insufficient numbers of nursing and personal care staff
in rural areas. Representatives of providers we interviewed stated that
significant distances between residents in rural areas make it
difficult to provide family and caregiver support, such as respite
care, and supportive services, such as personal care services. The
length of time it takes for personal care staff to travel between
individuals in rural areas decreases the number of services the
providers can deliver in a day. In addition, representatives of
providers told us that increases in fuel costs have affected how many
services they can provide. Representatives of providers we interviewed
also described how unpaved roads and inclement weather can increase
travel time or prevent travel entirely when serving rural residents.
Representatives of one provider stated that the challenge of providing
transportation in rural areas is one of the barriers that has prevented
the provider's expansion into rural areas of the state.
Representatives of providers we interviewed also cited the limited
availability of certain services in rural areas as a challenge to
serving individuals nearing the end of life who reside in those areas.
Representatives of providers described difficulties in delivering
supplies and medications to rural residents. For example,
representatives of a hospice-based palliative care provider noted that
the pharmacy service it contracts with to provide home delivery of
medications cannot provide daily delivery in very rural areas and
inclement weather may further delay deliveries. To address the problem,
this provider has contracted with local rural pharmacies to provide
emergency medication; however, in a two-county area, only one pharmacy
is open 24 hours a day, making it difficult for individuals to access
medications in an emergency. Representatives of another hospice-based
palliative care provider and a WPP provider stated that they are
sometimes unable to coordinate supportive services, such as meal
delivery and personal care services, for individuals in rural areas
because they are unable to locate providers of these services in these
regions. In addition, representatives of providers noted that a lack of
transit services makes it difficult to provide individuals living in
rural areas with transportation to medical appointments or day centers.
Representatives of providers stated that an insufficient number of
nursing staff and personal care workers in rural areas makes it
difficult to provide end-of-life care to those residents. For example,
representatives of a provider of both PACE and WPP noted that it is
often difficult to hire staff to work in more remote geographic areas,
and they cited this as a barrier to expanding the provider's services
into additional rural areas of the state. In addition, representatives
of one hospice-based palliative care provider that serves a remote
rural area stated that they have been unable to maintain adequate
numbers of health care workers to provide services to its patients
because such workers are increasingly choosing to relocate to urban
areas. Representatives of another hospice-based palliative care
provider in a rural region also stated that they have difficulty
finding qualified staff to fill these positions.
State officials we interviewed said that PACE is not a feasible option
in rural areas because of the requirement that the providers operate an
adult day center. Representatives of a provider that was formerly a
PACE provider stated that it was difficult to remain financially
solvent as a PACE provider in a rural community because there were not
enough eligible individuals to support an adult day center model. This
provider ended its participation in PACE because the community it
served did not have enough eligible individuals to justify the expense
of a day center. Also, in rural areas, the distance to the PACE adult
day center from the residences of individuals enrolled in the program
can be a challenge for the PACE program's transportation services.
Providers Encounter Physician Training and Practices as Challenges to
Providing Pain and Symptom Management and Advance Care Planning:
Representatives of providers we interviewed described how they believe
physician training and practices may present challenges to providing
pain and symptom management and advance care planning to individuals
nearing the end of life. Representatives of providers stated that
physicians often do not receive adequate training in pain and symptom
management. A physician we interviewed who is the director of a
hospital-based palliative care program stated that he believes because
physicians lack training to recognize the need for pain and symptom
management, individuals nearing the end of life often have difficulty
accessing such services.[Footnote 18] Representatives of other
palliative care providers we interviewed agreed that lack of physician
training in pain and symptom management is a challenge to the provision
of pain and symptom management. Representatives of a hospital-based
palliative care provider believe that many medical schools do not
provide sufficient training for physicians in pain and symptom
management. Representatives of a palliative care provider operated by a
health care system stated that they believe most physicians are not
trained to provide pain and symptom management to individuals nearing
the end of life. A recent article in the New England Journal of
Medicine (NEJM) has also noted that physicians receive little or no
training in the use of medications for pain and symptom
management.[Footnote 19]
Representatives of providers we interviewed also cited physician
practices as challenges to individuals receiving pain and symptom
management services as they near the end of life. A representative of a
hospital-based palliative care provider stated that some physicians are
reluctant to refer individuals to the program so that they can receive
pain and symptom management because these physicians do not understand
or recognize the need for such care. Representatives of providers we
interviewed also described how, in their experience, physicians may
fail to address pain in a timely manner. A representative of a hospital-
based palliative care provider stated that patients' severe pain may go
untreated while physicians, intent on finding the cause of the pain,
order extensive diagnostic testing. Representatives of a palliative
care program operated by a health care system stated that some
physicians perform aggressive medical procedures on individuals nearing
the end of life. These representatives stated that they believe some
physicians view providing pain and symptom management as "giving up" on
a patient.
Representatives of providers we interviewed described how physicians
often do not engage in advance care planning with individuals nearing
the end of life. For example, representatives of a hospice-based
palliative care provider stated that they believe physicians do not
spend enough time talking with individuals about end-of-life care
options such as hospice. As was recently reported in NEJM, physicians
receive little training in the compassionate discussion of end-of-life
issues.[Footnote 20] Furthermore, ALTCS officials stated that, in their
experience, physicians often do not inform individuals about advance
directives. Representatives of a hospice-based palliative care provider
stated that physicians sometimes provide individuals with incorrect
information about care options for the end of life. Representatives of
a PACE provider told us that some physicians resist ending curative
care to allow individuals nearing the end of life to receive only
supportive care services, and the article published in NEJM reported
that some physicians regard the death of patient as a professional
failure.[Footnote 21]
Agency Comments and Our Evaluation:
In commenting on a draft of this report, CMS stated that the report is
a useful description of a diverse set of provider types in very
different settings, each of which provides useful services to persons
coming to the end of life. CMS noted that the report is especially
helpful as a time approaches when more Americans will be living with
serious and eventually fatal chronic conditions. CMS also stated that
it was useful that our report included individuals living with serious
chronic conditions who might live for some years. However, CMS
suggested that we avoid using the term terminal illness when referring
to such individuals. We note that, in our draft report, we used this
term only in the context of discussing the Medicare hospice benefit,
which is, by definition, a benefit for individuals with terminal
conditions. CMS also stated that we should mention other important
components of end-of-life care including, for example, having the
appropriate medical diagnosis and having all possible opportunities for
a meaningful life. However, these issues are beyond the scope of our
report. CMS also provided technical comments, which we incorporated
where appropriate. CMS's comments are reprinted in appendix I.
As agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution of it until 30
days from its date. At that time, we will send copies of this report to
the Administrator of CMS and to other interested parties. We will also
make copies available to others upon request. In addition, this report
will be available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or kingk@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made major contributions to
this report are listed in appendix II.
Sincerely yours,
Signed by:
Kathleen King:
Director, Health Care:
[End of section]
Appendix I: Comments from the Centers for Medicare & Medicaid Services:
Department Of Health & Human Services:
Centers for Medicare & Medicaid Services:
Office of the Administrator:
Washington, DC 20201:
Oct 12, 2007:
To: Kathleen King:
Director, Health Care:
Government Accountability Office:
From: Kerry Weems:
Acting Administrator:
Subject: Government Accountability Office's (GAO) Draft Report: "End-of-
Life Care: Key Components Provided by Programs in Four States" (GAO-08-
66):
Thank you for the opportunity to review and comment on the above
referenced subject draft report. We appreciate the GAO's interest in
end-of-life care. The Centers for Medicare & Medicaid Services (CMS)
is, as always, concerned about the quality of care provided.
This report is useful in describing a diverse set of provider types in
quite different settings, each of which is providing very useful
service to persons coming to the end of life. It is quite helpful to
have such a wide-ranging inquiry and description, especially as we
approach a time when so many more Americans will be living with serious
and eventually fatal conditions. CMS noted a few items that might
readily be addressed in order to make the report even more clear.
We find it very useful that the report includes persons living with
serious chronic conditions who might live for some years. The Program
of All-Inclusive Care for the Elderly (PACE) and other programs do not
require a reliable expectation of dying soon that is inherent in the
prognostic requirement for hospice. It would be good to make this point
explicitly, and to avoid using the term "terminal illness" in order to
avoid the sense that "dying" is a clearly definable phase of life.
Usually explicit terms like "living with eventually fatal illness" or
"coming to the end of life" are more informative to the reader. If the
report explicitly used the trajectories model (e.g., from the IOM
report, or from the June Milbank Quarterly article by Lynn et al), the
uncertainty over the timing of death might make more sense to the
reader. This could just be footnoted.
We would note with approval that the current CMS work to provide
patient assessments across provider types (the Continuity Assessment
Record and Evaluation instrument and demonstration) would sustain and
spread the good work that is mentioned on the middle
Centers for Medicare & Medical Services of page 20, in which PACE and
palliative care are finding that shared electronic records help quality
of care.
There are a few items of "context" that are so important in the care of
all patients that they are probably not mentioned in site visits.
Nevertheless, even for persons coming to the end of life, such
conventionally important elements as these continue to be important:
(I) having the appropriate medical diagnosis and treatment
interventions; (2) counting on reliable services 24/7, across settings
and time; and (3) having all possible opportunities for meaningful life
(including personal relationships, spiritual experience, and productive
work). Most likely, the programs visited, and the visitors, assumed
that these were part of the package. However, they are well worth
noticing, since otherwise it seems that care near the end of life might
not have to prioritize these elements. This could be added in a short
sentence or even a footnote, just to be clear that they still matter.
This is a very useful project and well-reported and will be of help in
our work to ensure quality and value in care for persons living with
fatal illness. Thank you for the opportunity to review the draft. We
appreciate the insights gained from the site visits and so helpfully
documented.
[End of section]
Appendix II: GAO Contact and Staff Acknowledgments:
GAO Contact:
Kathleen King, (202) 512-7114 or kingk@gao.gov:
Acknowledgments:
In addition to the contact named above, key contributors to this report
were Nancy A. Edwards, Assistant Director; Beth Cameron Feldpush;
Krister Friday; John Larsen; and Andrea E. Richardson.
[End of section]
Footnotes:
[1] Medicare is the federal health care program for elderly and certain
disabled individuals.
[2] Medicaid is the joint federal-state program that provides health
coverage for certain low-income individuals. Medicaid also pays for
long-term care services, including nursing home care.
[3] Medicare covers some skilled nursing care following a covered
hospital stay.
[4] Personal care services can be provided in the home and assist
individuals with activities of daily living, such as bathing, dressing,
or eating.
[5] Testimony by Mark B. McClellan, MD, PhD, Administrator of CMS,
before the Subcommittee on Health, House Committee on Energy and
Commerce on April 27, 2005.
[6] Curative care is care intended to overcome a disease and promote
recovery. Under the hospice benefit, the beneficiary retains Medicare
coverage for services to treat conditions other than the terminal
illness or related conditions.
[7] Institute of Medicine, Committee on Care at the End of Life,
Approaching Death: Improving Care at the End of Life (Washington, D.C.:
National Academy Press, 1997).
[8] K. Lorenz et al., End-of-Life Care and Outcomes, Evidence Report/
Technology Assessment No. 110, AHRQ Publication No. 05-E004-2
(Rockville, Md.: Agency for Healthcare Research and Quality, December
2004). Prepared by the Southern California Evidence-based Practice
Center, under contract No. 290-02-0003.
[9] Low health care service utilization may result from use of
coordinated care as well as from other factors such as underservice.
[10] One of the WPP providers is also a PACE provider.
[11] Four of these programs are administered by hospitals, two are
administered by health care systems, and six are administered by
hospices. The palliative care programs administered by these hospices
are separate from the hospice program.
[12] Although the PACE benefit package must include Medicare covered
services, under Medicare regulations only PACE enrollees who are
eligible for Medicare must be furnished Medicare services.
[13] Respite care is services that provide temporary relief from tasks
associated with caring for individuals who are ill.
[14] Under section 1115 of the Social Security Act, CMS has authority
to waive certain statutory requirements of the Medicaid program for
states to engage in experimental, pilot, or demonstration projects that
promote Medicaid program objectives. While many states choose to
operate limited waiver programs for targeted populations, Arizona has
chosen to operate its entire Medicaid program under a demonstration
waiver.
[15] Advance directives are documents that communicate an individual's
wishes about end-of-life care (for example, preferences about the use
of medical interventions such as a feeding tube or breathing machine)
in the event that the individual is unable to communicate, and include
living wills and medical powers of attorney.
[16] An environmental adaptation is equipment or physical adaptations
to an individual's home that enable the individual to have greater
independence and functional access and ensure the health and safety of
the individual. For example, installing equipment in a bathroom to make
it more accessible for an individual with mobility impairments is an
environmental adaptation.
[17] The POLST form was developed by a multidisciplinary task force of
health care professionals and representatives from governmental
organizations and health care institutions in Oregon.
[18] In September 2006, the American Board of Medical Specialties
(ABMS) approved the development of Hospice and Palliative Medicine as a
subspecialty. As a result of this approval, the first ABMS-recognized
examinations for this subspecialty will likely be administered in 2008.
[19] G. Gazelle, "Understanding Hospice - An Underutilized Option for
Life's Final Chapter," The New England Journal of Medicine, vol. 357,
no. 4 (2007), 321-324.
[20] Gazelle, "Understanding Hospice - An Underutilized Option for
Life's Final Chapter."
[21] Gazelle, "Understanding Hospice - An Underutilized Option for
Life's Final Chapter."
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "Subscribe to Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office:
441 G Street NW, Room LM:
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Gloria Jarmon, Managing Director, JarmonG@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
