This is the accessible text file for GAO report number GAO-14-52 
entitled 'Health Resources and Services Administration: Review of 
Internal Communication Mechanisms, Staffing, and Use of Contracts' 
which was released on January 2, 2014. 

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. 

United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

December 2013: 

Health Resources and Services Administration: 

Review of Internal Communication Mechanisms, Staffing, and Use of 
Contracts: 

GAO-14-52: 

GAO Highlights: 

Highlights of GAO-14-52, a report to congressional requesters. 

Why GAO Did This Study: 

HRSA is charged with improving access to health care services for 
people who are uninsured, isolated, or medically vulnerable. HRSA 
carries out its mission by providing funding and support to a wide 
variety of programs, which have grown in number and size since the 
agency was established in 1982. To manage these programs, HRSA has a 
staff of nearly 1,900 employees, supplemented by contract staff who 
perform a variety of tasks to support HRSA’s programs and operations. 
HRSA’s staff are organized into seven programmatic bureaus that are 
responsible for overseeing HRSA’s programs and nine cross-cutting 
operational support offices-—each of which reports to the Office of 
the Administrator. In recent years, GAO reported on weaknesses in 
HRSA’s oversight and monitoring of certain programs. 

Given GAO’s past findings and the expansion of the agency’s programs, 
GAO was asked to review HRSA’s management and operations. This report 
examines (1) HRSA’s internal communication mechanisms and how they are 
used to support the agency’s mission; (2) HRSA’s staffing and how the 
agency plans for attrition; and (3) HRSA’s use of contracts to support 
its operations. GAO reviewed and analyzed HRSA’s communication methods 
and organizational structure; analyzed data on HRSA personnel and 
contracts for fiscal years 2008 through 2012; interviewed HRSA 
officials knowledgeable about the agency’s organization, staffing, and 
use of contracts; and reviewed relevant documentation. 

What GAO Found: 

The Department of Health and Human Services’ (HHS) Health Resources 
and Services Administration (HRSA) has mechanisms in place to share 
information important for supporting the agency’s mission across its 
various organizational components and levels of staff-—a practice that 
is consistent with internal control standards for the federal 
government. These communication methods include an annual operational 
planning process for allocating agency resources, workgroups that 
involve staff from across the agency to work on issues of a cross-
cutting nature, and regular meetings between the Office of the 
Administrator and leaders of the agency’s various organizational 
components. 

HRSA’s staff grew by more than 30 percent from fiscal years 2008 to 
2012. The number of HRSA employees grew from 1,418 in fiscal year 2008 
to 1,857 in fiscal year 2012. According to agency officials, the most 
common job function within HRSA is a project officer—-an employee 
responsible for the oversight of grantees funded by the agency’s 
programs; and HRSA has over 400 project officers. From fiscal years 
2008 through 2012, HRSA lost an average of 9 percent of its staff 
annually to attrition. Of those who left HRSA in fiscal year 2012, 
approximately 59 percent resigned and 35 percent retired. Agency-wide, 
over 30 percent of HRSA’s permanent employees will be eligible to 
retire by the end of fiscal year 2017. An even larger portion of 
HRSA’s leadership, nearly 50 percent, will be eligible to retire by 
2017. If a large portion of the agency’s leadership were to actually 
retire during this time period, HRSA runs the risk of having gaps in 
leadership and potential loss of important institutional knowledge. 
HRSA periodically tracks attrition and retirement eligibility. To 
respond to retirements and other attrition, HRSA has instituted 
succession planning efforts which generally focus on leadership 
development for agency staff. For example, HRSA has instituted two 
leadership development programs, has two other programs under 
development, and has established mentoring and coaching programs. 

In fiscal year 2012, HRSA obligated over $240 million, or about 3 
percent of its appropriations, to contracts to acquire goods and 
services necessary to support its operations, an amount that has 
generally remained steady over the past few years. Over half of the 
fiscal year 2012 contract obligations were for two categories of 
services—-information technology and telecommunications services, and 
professional support services, which includes providing technical 
assistance to grantees. According to HRSA officials, the agency uses 
contracts to support its operations for a variety of reasons; these 
include supplementing HRSA staff or fulfilling short-term needs and 
performing functions that require specialized skills for which HRSA 
staff do not have the appropriate expertise, such as clinical or 
financial expertise. 

We provided a draft of this report to HHS for its review. In its 
written comments, HHS noted that the report recognized the mechanisms 
HRSA has in place to ensure the coordinated flow of communication and 
plan for succession. 

View [hyperlink, http://www.gao.gov/products/GAO-14-52]. For more 
information, contact Debra A.Draper at (202) 512-7114 or 
draperd@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

HRSA Has Mechanisms in Place for Multi-Directional Communication 
Throughout the Agency: 

HRSA's Staff Has Grown in Recent Years; About Half of Its Leadership 
Will Be Eligible to Retire by 2017: 

HRSA Obligated Over $240 Million for Contracts in Fiscal Year 2012, 
the Majority of Which Were for Information Technology and Program 
Support: 

Agency Comments: 

Appendix I: Health Resources and Services Administration's (HRSA) 
Programs by Programmatic Bureau, Fiscal Year 2013: 

Appendix II: HRSA Contracts with the Highest Total Amount of 
Obligations by Organizational Component, Fiscal Year 2012: 

Appendix III: Top Three Products or Services Obtained through 
Contracts by Organizational Component, Fiscal Year 2012: 

Appendix IV: Comments from the Department of Health and Human Services: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Overview of HRSA's Programmatic Bureaus and Operational 
Support Offices, as of September 2013: 

Table 2: HRSA Contract Obligations by Category, Fiscal Year 2012: 

Table 3: Amount of HRSA Contract Obligations by Organizational 
Component, Fiscal Year 2012: 

Figures: 

Figure 1: HRSA's Appropriations, Fiscal Years 1982 through 2012: 

Figure 2: Locations of HRSA Employees as of September 2013: 

Figure 3: HRSA's Organizational Chart as of September 2013: 

Figure 4: Number of HRSA Staff by Location, Fiscal Years 2008 through 
2012: 

Figure 5: Number of HRSA Employees by Organizational Component and 
Location, Fiscal Year 2012: 

Figure 6: Percent of HRSA Staff by Pay Plan, Fiscal Year 2012: 

Figure 7: HRSA Attrition Rates by Organizational Component, Fiscal 
Year 2012: 

Figure 8: Percent of HRSA Employees Eligible to Retire by Fiscal Year 
2017, by Organizational Component: 

Figure 9: Amount of HRSA Contract Obligations, Fiscal Years 2008 
through 2012: 

Abbreviations: 

ARRA: American Recovery and Reinvestment Act of 2009: 

FPDS-NG: Federal Procurement Data System-Next Generation: 

GS: General Schedule: 

HHS: Department of Health and Human Services: 

HIV/AIDS: human immunodeficiency virus and acquired immunodeficiency 
syndrome: 

HPSA: health professional shortage area: 

HRSA: Health Resources and Services Administration: 

PPACA: Patient Protection and Affordable Care Act: 

SES: Senior Executive Service: 

[End of section] 

GAO:
United States Government Accountability Office: 
441 G St. N.W. 
Washington, DC 20548: 

December 3, 2013: 

Congressional Requesters, 

The Health Resources and Services Administration (HRSA), an agency 
within the Department of Health and Human Services (HHS), is charged 
with improving access to health care services for people who are 
uninsured, isolated, or medically vulnerable. HRSA's scope of work has 
evolved since it was established in 1982 and its programs have grown 
in number and size. According to information provided by HRSA, in the 
last decade, the agency's appropriation has also increased in nominal 
dollars from approximately $7.2 billion in fiscal year 2003 to about 
$8.1 billion in fiscal year 2013. Some of the agency's recent growth 
is due to additional authority, responsibilities, and funding for HRSA 
programs provided through the American Recovery and Reinvestment Act 
of 2009 (ARRA)[Footnote 1] and the Patient Protection and Affordable 
Care Act (PPACA).[Footnote 2] According to HRSA, ARRA provided an 
additional $2.5 billion from fiscal years 2009 through 2011 and PPACA 
authorized an additional $8.2 billion for the agency's programs from 
fiscal years 2010 through 2014.[Footnote 3] While HRSA's programs and 
responsibilities have expanded, the agency is also facing new 
challenges as a result of sequestration,[Footnote 4] which led the 
agency to implement a hiring freeze in January 2013. 

To carry out its mission "to improve health and achieve health equity 
through access to quality services, a skilled health workforce, and 
innovative programs," HRSA provides leadership and financial support 
to more than 3,000 grantees, including organizations in every state. 
These grantees serve millions of people each year through a variety of 
HRSA-sponsored programs. For example, through its Health Center 
Program, HRSA awards grants to nonprofit community-based or public 
organizations that provide comprehensive primary care services to 
millions of people regardless of their ability to pay for care. HRSA 
also provides funding for poison control centers; programs for organ, 
bone marrow, and cord blood donation; and scholarships to students and 
loan repayment to health care providers who agree to work in 
underserved areas. HRSA also has programs that award grants to 
organizations that provide health care to people living with human 
immunodeficiency virus and acquired immunodeficiency syndrome 
(HIV/AIDS); pregnant women, mothers, and children; and people living 
in rural communities. 

To manage its diverse array of programs, HRSA has a staff of almost 
1,900 employees, supplemented by contract staff who perform a variety 
of tasks to support HRSA's programs and operations. HRSA staff are 
organized into the Office of the Administrator and 16 other 
organizational components--7 programmatic bureaus that are responsible 
for overseeing HRSA's programs, and 9 cross-cutting operational 
support offices--each of which reports to the Office of the 
Administrator. Staff must communicate across these bureaus and offices 
to accomplish certain tasks such as planning for the agency's budget, 
allocating staff, implementing the HRSA-related provisions in PPACA, 
and overseeing grantees. 

In recent years, we reported on weaknesses in HRSA's oversight and 
monitoring of certain programs. For example, in 2011, we reported that 
HRSA's oversight of the 340B Drug Pricing Program--a program through 
which drug manufacturers give certain covered entities access to 
discounted prices on outpatient drugs--was inadequate to ensure that 
covered entities were in compliance with program requirements. 
[Footnote 5] In addition, in 2012, we reported that HRSA did not 
consistently follow HHS regulations and guidance in its oversight of 
grantees under the Ryan White Comprehensive AIDS Resources Emergency 
Act of 1990.[Footnote 6] We also reported in 2012 that HRSA's 
oversight of its Health Center Program grantees was insufficient to 
ensure that the agency consistently identified all instances of 
grantee noncompliance with Health Center Program requirements. 
[Footnote 7] 

Given our past findings of weaknesses in HRSA's oversight of certain 
programs, the importance of the agency's programs to low-income and 
underserved populations, and the expansion of the agency's programs, 
you asked us to review HRSA's management and operations, including how 
the agency uses contracts to support its operations. In this report, 
we examine (1) HRSA's internal communication mechanisms and how they 
are used to support the agency's mission; (2) HRSA's staffing and how 
the agency plans for attrition; and (3) how HRSA uses contracts to 
support its operations.[Footnote 8] 

To examine HRSA's internal communication mechanisms and how they are 
used to support the agency's mission, we reviewed and analyzed HRSA's 
methods of communication, organizational structure, and reporting 
arrangements overall and at the bureau and office level. In addition, 
we interviewed the leaders of each bureau and selected operational 
support offices, as well as agency-level officials about a range of 
management practices related to communication among agency, bureau, 
and office leaders. We reviewed relevant documents such as 
organizational charts, meeting minutes, and agency reports and memos. 
As part of our review, we assessed whether HRSA's communication 
mechanisms and practices were consistent with internal controls 
related to communication.[Footnote 9] 

To examine HRSA's staffing and how the agency plans for attrition, we 
analyzed trends in HRSA personnel data for the most recent five-year 
period, fiscal years 2008 through 2012, from the Office of Personnel 
Management's Enterprise Human Resources Integration-Statistical Data 
Mart (formerly the Central Personnel Data File) for civilian employees 
and HHS's Commissioned Corps Personnel and Payroll System for 
employees in the U.S. Public Health Service Commissioned Corps. 
[Footnote 10] For our analysis we combined data from both systems to 
create a complete picture of HRSA's staff. We analyzed data from these 
two systems to determine: 

* the number of staff overall and by location, organizational 
component, and pay plan;[Footnote 11] 

* attrition rates and the reasons for attrition, which include 
resignation, retirement, termination, and death;[Footnote 12] and, 

* retirement eligibility for HRSA staff from fiscal years 2012 through 
2017, by using birth date and service computation date, as well as 
retirement eligibility requirements for civilian employees and 
Commissioned Corps officers.[Footnote 13] 

To determine the reliability of data obtained from the Office of 
Personnel Management's Enterprise Human Resources Integration-
Statistical Data Mart, we reviewed the data system's technical 
documentation and compared output from our analysis to information 
provided by HRSA to ensure the information was consistent across 
sources. To determine the reliability of data obtained from the 
Commissioned Corps Personnel and Payroll System, we conducted 
interviews with officials knowledgeable about the system to understand 
the actions taken to ensure the data's consistency, accuracy, and 
completeness. We also conducted electronic data testing for data 
reliability for both systems. We determined that the data obtained 
from both systems were sufficiently reliable for our purposes. In 
addition to analyzing data on HRSA staffing, we interviewed HRSA 
officials including the leaders of each programmatic bureau regarding 
staffing allocation decisions, practices, and challenges, as well as 
the agency's tracking and planning for staff attrition and 
retirements. We also reviewed relevant documentation, such as 
strategic plans to identify HRSA's approach to staff planning, 
including for allocation, attrition, and retirements. Finally, we 
assessed HRSA's practices against best practices for human capital 
management and planning.[Footnote 14] 

To examine how HRSA uses contracts to support its operations, we 
analyzed data on HRSA's contracts from the Federal Procurement Data 
System-Next Generation (FPDS-NG), the primary government-wide 
contracting database which provides information on government 
contracting actions and procurement trends. We focused our review on 
contracts with obligations in fiscal year 2012 to determine dollar 
amounts of contract obligations agency-wide and by organizational 
component, as well as key characteristics of contracts used to support 
the agency's operations. To assess whether HRSA's use of contracts has 
changed significantly over time, we also reviewed data on the agency's 
contracts with obligations in fiscal years 2008 through 2011. To 
assess the reliability of the HRSA data we obtained from FPDS-NG, we 
reviewed recent audits and certifications of HRSA's contract data, 
compared the data we obtained with data provided by HRSA, and 
conducted electronic data testing to look for obvious data errors. 
Based on this, we determined that the data were sufficiently reliable 
for our purposes. To supplement the data from FPDS-NG, we obtained 
information manually compiled by HRSA on the organizational component 
supported by each contract with obligations in fiscal year 2012. We 
also interviewed HRSA officials knowledgeable about the agency's 
contracts, contracting data, and approach to determining when and how 
to use contractors, and leaders of HRSA's programmatic bureaus about 
how the bureaus use contracts to support their programs. In addition, 
we reviewed relevant documentation about HRSA's process for requesting 
and approving the need for contract support such as procurement plan, 
operating plan, and decision memo documentation. 

We conducted this performance audit from January 2013 to December 2013 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

HRSA was established in 1982, and its mission is to improve health and 
achieve health equity through access to quality services, a skilled 
health workforce, and innovative programs. HRSA's strategic plan 
contains four main goals: (1) improve access to quality health care 
and services, (2) strengthen the health workforce, (3) build healthy 
communities, and (4) improve health equity. HRSA also has a human 
capital strategic plan meant to ensure that the agency has the 
workforce it needs to carry out its mission. That plan contains five 
main goals: (1) plan for and align the workforce to ensure employees 
have the right experience and skills to fit the job, (2) support 
continuous learning, (3) build leadership bench strength,[Footnote 15] 
(4) strengthen the performance culture, and (5) improve employee 
satisfaction. As of September 2013, HRSA was in the process of 
updating its human capital strategic plan for the 2013 through 2015 
timeframe. 

Overview of HRSA Operations: 

According to information from HRSA, the agency had appropriations of 
about $8.1 billion in fiscal year 2013. Since its inception in 1982, 
HRSA's appropriations have generally increased in real terms. (See 
figure 1.) Increases to HRSA's appropriations since fiscal year 2009 
can partially be attributed to ARRA and PPACA. According to HRSA, ARRA 
provided an additional $2.5 billion to the agency from fiscal years 
2009 through 2011. HRSA received approximately $7.8 billion through 
PPACA from fiscal years 2010 through 2013, and is expecting another 
$400 million in fiscal year 2014, for a total of about $8.2 billion 
over the 5 years. 

Figure 1: HRSA's Appropriations, Fiscal Years 1982 through 2012: 

[Refer to PDF for image: vertical bar graph] 

Funding in 2012 dollars[A]: 

Fiscal Year: 1982; 
Adjusted Appropriation: $4.580 billion. 

Fiscal Year: 1987; 
Adjusted Appropriation: $2.767 billion. 

Fiscal Year: 1992; 
Adjusted Appropriation: $4.170 billion. 

Fiscal Year: 1997; 
Adjusted Appropriation: $5.101 billion. 

Fiscal Year: 2002; 
Adjusted Appropriation: $8.111 billion. 

Fiscal Year: 2007; 
Adjusted Appropriation: $7.272 billion. 

Fiscal Year: 2012; 
Adjusted Appropriation: $8.461 billion. 

Source: GAO analysis of HRSA data. 

[A] Appropriation amounts are adjusted using the U.S. Department of 
Commerce, Bureau of Economic Analysis, Gross Domestic Product Price 
Index. 

[End of figure] 

According to HRSA, in fiscal year 2012 the agency used over 90 percent 
of its budget on funding for its programs through grants, cooperative 
agreements, scholarships and loan repayments, and other forms of 
programmatic funding.[Footnote 16] In addition to these funding 
mechanisms, HRSA uses contracts--award mechanisms used to acquire 
services or property from a non-federal party for the benefit or use 
of HRSA--to support its operations and programs. 

Through these mechanisms, HRSA provides funding and support for a wide 
variety of programs. HRSA's programs include a block grant to fund 
services for maternal and child health across the country, 
compensation for people injured by vaccines, grants to a national 
network of health centers to provide primary health care, loan 
repayment and scholarships for recruiting and training health care 
providers who practice in underserved communities, and grants to 
organizations providing services for people living with HIV/AIDS. 
[Footnote 17] As a result of ARRA and PPACA, HRSA has expanded some of 
its programs, and started new programs in recent years. For example, 
HRSA expanded its Health Center Program and established a Home 
Visiting Program to improve coordination of services and outcomes for 
families living in at-risk communities.[Footnote 18] 

HRSA's staff of nearly 1,900 provides oversight, technical assistance, 
and operational support for the agency's programs. Its workforce 
consists of permanent civilian staff, including those within the 
General Schedule (GS) employment system, the Senior Executive Service 
(SES), and other government pay plans.[Footnote 19] HRSA also employs 
staff from the Commissioned Corps. In addition to permanent civilian 
and Commissioned Corps staff, HRSA also employs some nonpermanent 
staff. For example, for its grant review panels, advisory committees, 
and certain other activities, HRSA may hire individuals for discrete, 
time-limited activities for which a particular expertise is needed. 
HRSA has headquarters staff who are assigned to the agency's 
headquarters in Rockville, Maryland, and "regional staff" who work in 
1 of the agency's 10 regional offices or 1 of 2 field locations across 
the United States and Puerto Rico (see figure 2). 

Figure 2: Locations of HRSA Employees as of September 2013: 

[Refer to PDF for image: illustrated U.S. map] 

Headquarters: 
Rockville, Maryland. 

Regional offices: 
Atlanta, Georgia; 
Boston, Massachusetts; 
Chicago, Illinois; 
Dallas, Texas; 
Denver, Colorado; 
Kansas City, Missouri; 
New York City, New York; 
Philadelphia, Pennsylvania; 
San Francisco, California; 
Seattle, Washington. 

Field locations: 
Baton Rouge, Louisiana; 
Puerto Rico. 

Sources: GAO analysis of HRSA data; Map Resources (map). 

[End of figure] 

HRSA's Organizational Structure: 

HRSA's organization consists of the Office of the Administrator and 16 
other organizational components--7 programmatic bureaus and 9 cross-
cutting operational support offices (see figure 3).[Footnote 20] 

Figure 3: HRSA's Organizational Chart as of September 2013: 

[Refer to PDF for image: Organizational Chart] 

Top level: 
Office of the Administrator. 

Second level, reporting to Office of the Administrator: 
Programmatic Bureaus: 
* Bureau of Primary Health Care; 
* Maternal and Child Health Bureau; 
* Bureau of Health Professions; 
* Office of Rural Health Policy; 
* Healthcare Systems Bureau; 
* HIV/AIDS Bureau; 
* Bureau of Clinician Recruitment and Service. 

Third level, reporting to Office of the Administrator: 
Operational Support Offices: 
* Office of Communications; 
* Office of Legislation; 
* Office of Operations; 
* Office of Federal Assistance Management; 
* Office of Health Equity; 
* Office of Regional Operations; 
* Office of Equal Opportunity, Civil Rights, and Diversity Management; 
* Office of Planning, Analysis and Evaluation; 
* Office of Women’s Health. 

Source: HRSA. 

Note: HRSA considers the Office of Rural Health Policy to be a 
programmatic bureau as it is similar in function and organizational 
structure to the six units with "bureau" in their titles. 

[End of figure] 

HRSA's Office of the Administrator provides broad leadership and 
direction to HRSA staff and plans, directs, and interprets major 
policies, programs, and initiatives for the agency. The Office of the 
Administrator also makes final decisions about HRSA's organization, 
staff allocation, budget, and contracts. The office includes HRSA's 
Administrator, Deputy Administrator, and Senior Advisors. HRSA's seven 
programmatic bureaus each manage a portfolio of activities dealing 
with a specific area of health care services, systems, or workforce. 
Each of HRSA's bureaus is led by an Associate Administrator and Deputy 
Associate Administrator, who are generally members of the SES. The 
bureaus are organized into smaller components called divisions or 
offices that are led by a director, generally a GS-15, who reports to 
the bureau's Associate Administrator. Some of these divisions and 
offices are further broken down into subcomponents called branches 
which are led by chiefs who report to the division or office 
directors. HRSA's nine operational support offices provide assistance 
for the agency's programmatic work and coordination for cross-cutting 
or agency-wide issues, such as human resources, acquisitions 
management, and grants administration. (See table 1 for an overview of 
HRSA's bureaus and offices and appendix I for a list of HRSA programs 
by bureau.) 

Table 1: Overview of HRSA's Programmatic Bureaus and Operational 
Support Offices, as of September 2013: 

Programmatic Bureau: 

Organizational Component: Bureau of Clinician Recruitment and Service; 
Intended Purpose: Helps underserved communities and facilities 
experiencing critical shortages of health care providers recruit and 
retain clinicians through scholarship and educational loan repayment 
programs in exchange for services. 

Organizational Component: Bureau of Health Professions; 
Intended Purpose: Increases access to health care by developing, 
distributing, and retaining a diverse, culturally competent health 
workforce. 

Organizational Component: Bureau of Primary Health Care; 
Intended Purpose: Oversees, funds, and supports a national network of 
health centers that provide access to high quality, family oriented, 
comprehensive primary and preventive health care for people who are 
low income, uninsured, or living where health care is scarce. 

Organizational Component: Healthcare Systems Bureau; 
Intended Purpose: Provides infrastructure to protect, improve, and 
enhance public health including organ, bone marrow, and cord blood 
donation. 

Organizational Component: HIV/AIDS Bureau; 
Intended Purpose: Administers the Ryan White HIV/AIDS CARE Act 
Program, which is the largest federal program focused exclusively on 
HIV/AIDS care, and is for those who do not have sufficient health care 
coverage or financial resources for coping with HIV/AIDS. 

Organizational Component: Maternal and Child Health Bureau; 
Intended Purpose: Administers the Maternal and Child Health Block 
Grant to states, as well as discretionary grants to ensure that the 
nation's women, infants, children, adolescents, and their families, 
including fathers and children with special health care needs, have 
access to quality health care[A]. 

Organizational Component: Office of Rural Health Policy[B]; 
Intended Purpose: Promotes better health care services in rural areas. 
The office works both within government at federal, state, and local 
levels, and with the private sector--with associations, foundations, 
providers, and community leaders--to seek solutions to rural health 
care problems. 

Operational Support Office: 

Organizational Component: Office of Communications; 
Intended Purpose: Develops and implements national communication 
initiatives to inform and educate the public, health care 
professionals, policy makers, and the media; coordinates, researches, 
writes, and prepares speeches and audiovisual presentations for the 
agency; maintains the agency's social media presence; and coordinates 
with the Department of Health and Human Services' (HHS) Public Affairs 
staff. 

Organizational Component: Office of Equal Opportunity, Civil Rights, 
and Diversity Management; 
Intended Purpose: Provides advice, counsel, and recommendations to 
HRSA personnel, including regional divisions, on equal opportunity and 
civil rights. 

Organizational Component: Office of Federal Assistance Management; 
Intended Purpose: Serves as a central office for pre-award, award, 
administration and management, and close-out of the agency's grants 
and cooperative agreements in partnership with HRSA's programmatic 
bureaus. 

Organizational Component: Office of Health Equity; 
Intended Purpose: Serves as the principal advisor and coordinator to 
the agency for the special needs of minority and disadvantaged 
populations. 

Organizational Component: Office of Legislation; 
Intended Purpose: Provides advice on legislative affairs, including 
preparing analytic papers and reports on proposed legislation; 
conducting legislative research, monitoring hearings and congressional 
activities; and coordinating with HHS legislative staff on information 
requested by Congress. 

Organizational Component: Office of Operations; 
Intended Purpose: Serves as a central office for managing the agency's 
operations related to information technology, budgets, financial 
policy and controls, human resources functions, and acquisitions. 

Organizational Component: Office of Planning, Analysis and Evaluation; 
Intended Purpose: Serves as an agency resource for policy analysis, 
data synthesis, organizational planning, external liaison activities, 
research, evaluation, and performance and quality measurement. 

Organizational Component: Office of Regional Operations; 
Intended Purpose: Provides leadership on collaborative efforts between 
state health care leaders, agency managers, and program resources in 
each state to improve public health and health care systems. 

Organizational Component: Office of Women's Health; 
Intended Purpose: Provides leadership on women's health and sex/gender-
specific issues and policy for the agency and other HHS agencies. 

Source: HRSA. 

[A] A block grant is a type of grant where funding recipients have 
substantial discretion over the type of activities to support, with 
minimal federal administrative requirements or restrictions. 

[B] HRSA considers the Office of Rural Health Policy to be a 
programmatic bureau as it is similar in function and organizational 
structure to the six units with "bureau" in their titles. 

[End of table] 

HRSA's underlying organizational structure of bureaus and offices has 
been in place for some time; however, since 2010, the agency has made 
several organizational changes. These included creating new 
organizational components, expanding or otherwise changing the 
functions of some components, and consolidating functions in order to 
eliminate a component. In addition, HRSA has made minor organizational 
changes within bureaus, such as realigning branches or shifting 
oversight responsibility of certain programs, and the staff 
responsible for them, between or within bureaus. HRSA officials 
reported that organizational changes were generally made to improve 
agency efficiency. For example, in 2010, HRSA established the Office 
of Operations to consolidate three previously separate offices: (1) 
the Office of Information Technology; (2) the Office of Management; 
and (3) the Office of Financial Management, which consisted of 
procurement, budget, policy, and control functions. These offices had 
formerly each reported directly to the Office of the Administrator. 
With this restructuring, the Chief Operating Officer--a position 
created in 2010--gained responsibility for oversight of these 
functions. In at least one instance, HRSA made a change as a result of 
a legislative requirement, namely, in October 2011 HRSA made its 
Office of Women's Health, which was previously located within its 
Maternal and Child Health Bureau, a separate office in response to a 
requirement in PPACA that the office be established within the Office 
of the Administrator.[Footnote 21] Most recently, as a result of 
fiscal circumstances, including the sequester which went into effect 
in March 2013, and an ongoing hiring freeze in effect since January 
2013, HRSA eliminated its Office of Special Health Affairs and 
distributed most of its functions to other existing bureaus and 
offices.[Footnote 22] According to HRSA, the elimination of the Office 
of Special Health Affairs was made to reduce overhead costs and better 
utilize staff. 

HRSA Has Mechanisms in Place for Multi-Directional Communication 
Throughout the Agency: 

HRSA has mechanisms in place to share information important for 
supporting the agency's mission across various levels of staff in the 
agency, including among agency leaders, programmatic bureau and 
operational support office leaders, and staff. These communication 
mechanisms include the agency's operational planning process; cross-
cutting workgroups and meetings; and regular communications among the 
Office of the Administrator, leaders in the bureaus and offices, and 
agency staff. The mechanisms HRSA has in place are consistent with 
internal control standards for the federal government, which state 
that effective communications within organizations should occur in a 
broad sense with a flow of information down, across, and up the 
organization.[Footnote 23] 

HRSA officials have established an annual operational planning process 
to facilitate the exchange of information across the agency to plan 
its budget and allocation of other resources. According to HRSA 
officials, each bureau and office develops a proposal to request 
contracts, budget, and other resources for the coming fiscal year. 
Next, these proposals are shared and discussed among all bureau and 
office leaders to allow for coordination and to reduce the risk of 
duplication or overlap of resources. Finally, HRSA's Administrator 
makes a determination about resource allocation--such as budgets and 
contracts for the coming fiscal year--which is documented in a 
decision memo for each bureau and office.[Footnote 24] Agency 
officials told us that this process improves efficiency and reduces 
the chance for duplication of effort among the bureaus and offices. 

In addition, HRSA has established 20 active workgroups to coordinate 
across the agency's bureaus and offices on cross-cutting topics. For 
example, according to agency officials, HRSA established a workgroup 
in April 2010--following the passage of PPACA--to coordinate 
communications and activities related to the implementation of 
provisions in the act pertaining to HRSA. The workgroup includes 
senior leaders from across the agency or their designees. In November 
2012, HRSA established a Standard Operating Procedures Workgroup to 
monitor the implementation of standard operating procedures related to 
grantee oversight across bureaus, discuss the status of 
implementation, and to share successful practices regarding their use. 
Members include individuals who are tasked with leading the 
implementation of standard operating procedures within each bureau. 
Another workgroup--the HRSA Program Integrity Initiative Workgroup, 
launched in June 2010--is tasked with identifying risks to the 
agency's management of programs and working to reduce those risks by 
initiating new or improved oversight efforts. The workgroup is 
comprised of representatives from all bureaus and offices. Other 
established workgroups focus on issues such as providing technical 
assistance to potential grantees who may be new to the application 
process, analyzing requests for information technology capital 
projects, and monitoring performance of the agency's ongoing 
technology investments. In addition to the formal workgroups, 
officials in all the bureaus told us they regularly work with 
colleagues from other bureaus and offices as needed to coordinate on 
program areas where topics and issues overlap. 

HRSA also has mechanisms in place to ensure the flow of information up 
and down the organizational hierarchy, such as from the Office of the 
Administrator down to individual bureaus and offices. The Office of 
the Administrator uses a variety of standing meetings and reporting 
tools to communicate and exchange information with bureau and office 
leadership on a broad range of policy, program, and management 
matters. For example, HRSA's Administrator holds a weekly senior staff 
meeting with the leaders of all of HRSA's bureaus and offices. Topics 
for discussion include HRSA's budget, operations, and implementation 
of PPACA. During these meetings, bureau and office leaders have the 
opportunity to share their concerns and discuss issues that they think 
may be of interest to the other organizational components of the 
agency. In addition, officials told us that HRSA's Administrator, 
Deputy Administrator, and a Senior Advisor hold a meeting every other 
week with each of the bureaus' Associate Administrators to discuss any 
problems that arise concerning grantees, plans for upcoming grant 
awards, program integrity issues, and any other bureau news or 
updates. Officials indicated that HRSA's Administrator meets monthly 
with the directors from all nine operational support offices; 
officials from the Office of the Administrator also meet weekly for 
one-on-one discussions with the directors from most of these offices. 
In addition, the leaders of each of the bureaus told us they hold 
regular meetings with their staff such as one-on-one meetings with 
division directors, weekly senior staff meetings within the bureau 
where participants can raise issues of concern or topics for 
discussion, and "all-hands" meetings used to inform all bureau staff. 

In addition to participating in these standing meetings, bureau 
leaders make use of routine reports and other written communication to 
convey key programmatic information from the bureau to the Office of 
the Administrator. For example, bureau leaders provide monthly written 
updates on their programs and activities for inclusion in an agency-
level report for the Secretary of HHS. These reports include 
information about HRSA collaboration with other agencies, programmatic 
updates, status of efforts related to PPACA, areas of concern, and 
completed congressional testimonies. HRSA officials also prepare 
decision papers to outline policy options for the Administrator's 
consideration. For example, officials sent decision papers to the 
Administrator to outline proposals for organizational changes, such as 
the disbanding of the Office of Special Health Affairs. These papers 
outlined the rationale for the change, budget and staffing 
implications, and specific recommendations for the Administrator. 

HRSA's Staff Has Grown in Recent Years; About Half of Its Leadership 
Will Be Eligible to Retire by 2017: 

HRSA's staff has grown approximately 30 percent over the last 5 years. 
While the number of staff has grown, HRSA experienced attrition 
averaging 9 percent per year over the past five years. Looking 
forward, almost half of HRSA's leadership will be eligible to retire 
by fiscal year 2017. HRSA periodically tracks attrition and retirement 
eligibility and has focused its succession planning efforts on 
leadership development. 

HRSA's Staff Has Grown in Recent Years with the Largest Segment of 
Staff Concentrated at the GS-13 Level: 

HRSA's staff grew by more than 30 percent from fiscal years 2008 to 
2012; the number of HRSA employees at the end of each fiscal year grew 
from 1,418 in fiscal year 2008 to 1,857 in fiscal year 2012.[Footnote 
25] (See figure 4.) HRSA officials indicated that the staffing 
increases correspond in part with HRSA's increased responsibilities 
and funding due to ARRA and PPACA. The majority of HRSA's staff, about 
86 percent in fiscal year 2012, were stationed in HRSA's Rockville, 
Maryland headquarters. The remaining employees were regional staff who 
were located in one of HRSA's 10 regional offices or 2 field locations 
in the United States and Puerto Rico. While the overall number of 
staff grew, the total number of regional staff declined by about 14 
percent--from 311 in fiscal year 2008 to 269 in fiscal year 2012. 

Figure 4: Number of HRSA Staff by Location, Fiscal Years 2008 through 
2012: 

[Refer to PDF for image: stacked vertical bar graph] 

Fiscal year: 2008; 
Headquarters: 1,107; 
Regional: 311. 

Fiscal year: 2009; 
Headquarters: 1,202; 
Regional: 293. 

Fiscal year: 2010; 
Headquarters: 1,410; 
Regional: 273. 

Fiscal year: 2011; 
Headquarters: 1,595; 
Regional: 267. 

Fiscal year: 2012; 
Headquarters: 1,588; 
Regional: 269. 

Source: GAO analysis of data from the Enterprise Human Resources 
Integration-Statistical Data Mart and the Commissioned Corps 
Personnel and Payroll System. 

Note: HRSA's headquarters is located in Rockville, Maryland. HRSA also 
has "regional staff" who work in 1 of the agency's 10 regional offices 
or 1 of 2 field locations across the United States and Puerto Rico. 

[End of figure] 

HRSA's organizational components vary in size and how staff are 
distributed across headquarters and regions. As of the end of fiscal 
year 2012, the organizational component with the greatest number of 
staff was the Bureau of Primary Health Care (308 employees) and the 
one with the fewest staff, with 4 employees, was the Office of Women's 
Health. Eight of HRSA's organizational components--five programmatic 
bureaus and three operational support offices--had regional staff. The 
Office of Regional Operations had the largest number and proportion of 
regional staff--70 of 84 staff (83 percent), followed by the 
Healthcare Systems Bureau (40 percent) and the Bureau of Clinician 
Recruitment and Service (25 percent). (See figure 5.) 

Figure 5: Number of HRSA Employees by Organizational Component and 
Location, Fiscal Year 2012: 

[Refer to PDF for image: stacked horizontal bar graph] 

Number of employees: 

Organizational component: Office of the Administrator; 
Headquarters: 10; 

Programmatic Bureaus: 

Organizational component: Bureau of Clinician Recruitment and Service; 
Headquarters: 198; 
Regional: 67. 

Organizational component: Bureau of Health Professions; 
Headquarters: 176; 
Regional: 0. 

Organizational component: Bureau of Primary Health Care; 
Headquarters: 265; 
Regional: 43. 

Organizational component: Healthcare Systems Bureau; 
Headquarters: 89; 
Regional: 60. 

Organizational component: HIV/AIDS Bureau; 
Headquarters: 142; 
Regional: 0. 

Organizational component: Maternal and Child Health Bureau; 
Headquarters: 120; 
Regional: 20. 

Organizational component: Office of Rural Health Policy; 
Headquarters: 45; 
Regional: 2. 

Operational Support Offices: 

Organizational component: Office of Communications; 
Headquarters: 23; 
Regional: 0. 

Organizational component: Office of Equal Opportunity Civil Rights and 
Diversity Management; 
Headquarters: 19; 
Regional: 0. 

Organizational component: Office of Federal Assistance Management; 
Headquarters: 161; 
Regional: 0. 

Organizational component: Office of Legislation; 
Headquarters: 12; 
Regional: 0. 

Organizational component: Office of Operations; 
Headquarters: 235; 
Regional: 6. 

Organizational component: Office of Planning, Analysis and Evaluation; 
Headquarters: 35; 
Regional: 0. 

Organizational component: Office of Regional Operations; 
Headquarters: 14; 
Regional: 70. 

Organizational component: Headquarters: Office of Special Health 
Affairs; 
Headquarters: 40; 
Regional: 1. 

Organizational component: Office of Women's Health; 
Headquarters: 4; 
Regional: 0. 

Source: GAO analysis of data from the Enterprise Human Resources 
Integration-Statistical Data Mart and the Commissioned Corps 
Personnel and Payroll System. 

[A] The Office of Special Health Affairs was disbanded in June 2013 
and most of its functions and staff were distributed to other Bureaus 
and Offices. As part of this process, an Office of Health Equity, 
which was previously within the Office of Special Health Affairs, 
began reporting directly to the Office of the Administrator. 

[End of figure] 

As of the end of fiscal year 2012, HRSA's staff were employed in one 
of 76 job occupations.[Footnote 26] The 5 most common occupations 
were: Public Health Program Specialist (635 employees), Management and 
Program Analysis (336 employees), General Health Science (165 
employees), Grant Management (92 employees), and Miscellaneous 
Administration and Program (70 employees). Officials indicated that 
within HRSA, the most common job function is a project officer. HRSA 
has over 400 project officers who are responsible for the ongoing 
oversight of an assigned portion of program funding recipients, such 
as grantees. Individuals from different occupations may serve as 
project officers, as the project officer function is not a distinct 
occupation.[Footnote 27] 

The majority of HRSA's staff, 1601 individuals or 86 percent of the 
staff in fiscal year 2012, were civilians within the GS pay plan, with 
GS-13s representing the largest number of employees--651 staff members 
(35 percent of HRSA employees). The remaining HRSA staff were SES, 
Commissioned Corps officers, or employees paid under one of several 
additional civilian pay plans. (See figure 6 for the distribution of 
HRSA staff by pay plan.) Within HRSA, 510 staff members (27 percent) 
were GS-14s or above (including individuals in the SES)--individuals 
who are generally supervisors, according to HRSA officials. 

Figure 6: Percent of HRSA Staff by Pay Plan, Fiscal Year 2012: 

[Refer to PDF for image: pie-chart] 

Senior Executive Service: 1%; 
Commissioned Corps/other[A]: 12%; 
General Schedule (GS): 86%: 
- GS-1 to 8: 5%; 
- GS-9 to 11: 8%; 
- GS-12: 12%; 
- GS-13: 35%; 
- GS-14: 14%; 
- GS-15: 12%. 

Source: GAO analysis of data from the Enterprise Human Resources 
Integration-Statistical Data Mart and the Commissioned Corps 
Personnel and Payroll System. 

Notes: Due to rounding, percentages do not add to 100. 

[A] Other refers to employees in other federal pay plans, such as the 
federal wage system for hourly, blue collar employees and a pay plan 
for physicians and dentists. About 1 percent of HRSA's staff--18 
individuals--were in other pay plans, and 11 percent of the agency's 
employees--211 individuals--were in the U.S. Public Health Service 
Commissioned Corps, which is part of the United States Uniformed 
Services. 

[End of figure] 

HRSA's Attrition Averaged About 9 Percent Over the Past 5 Years; 
Almost Half of Its Leadership Will Be Eligible to Retire by Fiscal 
Year 2017: 

From fiscal years 2008 through 2012, HRSA lost an average of about 9 
percent of its staff per year to attrition.[Footnote 28] HRSA's annual 
attrition rates from fiscal years 2008 through 2012 ranged from a low 
of 7.6 percent in fiscal year 2009 to a high of 9.9 percent in fiscal 
year 2008.[Footnote 29] In fiscal year 2012, HRSA had an attrition 
rate of 8.8 percent. Of those who left HRSA in that year, 
approximately 59 percent resigned, 35 percent retired, and 4 percent 
were terminated or removed.[Footnote 30] 

Attrition rates varied by pay plan and organizational component. In 
fiscal year 2012, attrition ranged from a high of 16.1 percent among 
GS-1s through GS-8s to a low of 3.9 percent for SES employees. While 
three organizational components, including the Office of the 
Administrator, had no attrition in fiscal year 2012, the Office of 
Planning, Analysis, and Evaluation had an attrition rate over 21 
percent. Across HRSA's programmatic bureaus, attrition rates ranged 
from 6.1 percent in the Office of Rural Health Policy to 13.4 percent 
in the Bureau of Health Professions. (See figure 7.) 

Figure 7: HRSA Attrition Rates by Organizational Component, Fiscal 
Year 2012: 

[Refer to PDF for image: horizontal bar graph] 

Attrition rate: 

HRSA-wide attrition rate: 8.8%. 

Organizational component: Office of the Administrator: 0. 

Programmatic Bureaus: 

Organizational component: Bureau of Clinician Recruitment and Service: 
10.3%. 

Organizational component: Bureau of Health Professions: 13.4%. 

Organizational component: Bureau of Primary Health Care: 7.7%. 

Organizational component: Healthcare Systems Bureau: 9.8%. 

Organizational component: HIV/AIDS Bureau: 7.3%; 

Organizational component: Maternal and Child Health Bureau: 7.3%. 

Organizational component: Office of Rural Health Policy: 6.1%. 

Operational Support Offices: 

Organizational component: Office of Communications: 4.2%. 

Organizational component: Office of Equal Opportunity Civil Rights and 
Diversity Management: 14.6%. 

Organizational component: Office of Federal Assistance Management: 
6.1%. 

Organizational component: Office of Legislation: 0. 

Organizational component: Office of Operations: 5.2%. 

Organizational component: Office of Planning, Analysis and Evaluation: 
21.2%. 

Organizational component: Office of Regional Operations: 11.1%. 

Organizational component: Headquarters: Office of Special Health 
Affairs[A]: 15.9%; 

Organizational component: Office of Women's Health: 0. 

Source: GAO analysis of data from the Enterprise Human Resources 
Integration-Statistical Data Mart and the Commissioned Corps 
Personnel and Payroll System. 

Notes: In this report, attrition includes anyone who left HRSA, 
including those who left HRSA for jobs with other agencies within HHS. 

[A] The Office of Special Health Affairs was disbanded in June 2013 
and most of its functions and staff were distributed to other bureaus 
and offices. As part of this process, the Office of Health Equity, 
which was previously within the Office of Special Health Affairs, 
began reporting directly to the Office of the Administrator. 

[End of figure] 

Agency-wide, 31.3 percent of HRSA's permanent employees will be 
eligible to retire by the end of fiscal year 2017; a rate similar to 
that for the entire federal government.[Footnote 31] However, a larger 
portion of HRSA's leadership, nearly 50 percent, is eligible to retire 
in the next few years. Specifically, over 55 percent of HRSA's SES 
employees, who serve as the leaders of HRSA's bureaus and offices, and 
almost 50 percent of GS-15s, which include Division Directors, will be 
eligible to retire by the end of fiscal year 2017.[Footnote 32] 
Although eligibility to retire does not necessarily mean that 
employees will do so at the time they become eligible, if there were a 
large number of retirements among the agency's leadership during this 
time period, HRSA runs the risk of having gaps in leadership and 
potential loss of important institutional knowledge. 

Within HRSA, retirement eligibility rates also vary by organizational 
component. By fiscal year 2017, over 40 percent of the employees in 
HRSA's Office of the Administrator, the Healthcare Systems Bureau, the 
Maternal and Child Health Bureau, and several of HRSA's operational 
support offices, will be eligible to retire. (See figure 8.) 

Figure 8: Percent of HRSA Employees Eligible to Retire by Fiscal Year 
2017, by Organizational Component: 

[Refer to PDF for image: horizontal bar graph] 

Retirement eligibility rate: 

HRSA-wide attrition rate: 31.3%. 

Organizational component: Office of the Administrator: 50%. 

Programmatic Bureaus: 

Organizational component: Bureau of Clinician Recruitment and Service: 
27.7%. 

Organizational component: Bureau of Health Professions: 28%. 

Organizational component: Bureau of Primary Health Care: 21.8%. 

Organizational component: Healthcare Systems Bureau: 42.8%. 

Organizational component: HIV/AIDS Bureau: 34.2%; 

Organizational component: Maternal and Child Health Bureau: 42.1%. 

Organizational component: Office of Rural Health Policy: 27.6%. 

Operational Support Offices: 

Organizational component: Office of Communications: 43.4%. 

Organizational component: Office of Equal Opportunity Civil Rights and 
Diversity Management: 41.1%. 

Organizational component: Office of Federal Assistance Management: 
32.9%. 

Organizational component: Office of Legislation: 33.3%. 

Organizational component: Office of Operations: 31.9%. 

Organizational component: Office of Planning, Analysis and Evaluation: 
12.9%. 

Organizational component: Office of Regional Operations: 32.9%. 

Organizational component: Headquarters: Office of Special Health 
Affairs[A]: 45%; 

Organizational component: Office of Women's Health: 0. 

Source: GAO analysis of data from the Enterprise Human Resources 
Integration-Statistical Data Mart and the Commissioned Corps 
Personnel and Payroll System. 

Notes: This analysis of retirement eligibility is limited to career 
permanent employees onboard as of the end of fiscal year 2012. 

[A] The Office of Special Health Affairs was disbanded in June 2013 
and most of its functions and staff were distributed to other bureaus 
and offices. As part of this process, an Office of Health Equity, 
which was previously within the Office of Special Health Affairs, 
began reporting directly to the Office of the Administrator. 

[End of figure] 

HRSA Periodically Tracks Attrition and Retirement Eligibility; Agency 
Succession Planning Efforts Focus on Leadership Development: 

HRSA periodically tracks attrition and retirement eligibility data. 
Collecting and analyzing data on attrition rates and retirement 
eligibility are considered a fundamental element for measuring the 
effectiveness of human capital approaches in support of an agency's 
mission and goals.[Footnote 33] HRSA receives a quarterly report from 
HHS that provides agency-wide attrition data by reason for departure. 
Additionally, HRSA officials stated that staff in the Office of 
Operations track employee attrition data as needed for making agency-
wide hiring and budget decisions. According to these officials, staff 
attrition data is shared with leaders of the programmatic bureaus and 
operational support offices as requested, or when high rates of 
attrition occur. 

In addition to reviewing attrition data, officials from several 
bureaus reported that they use information from exit interviews to 
help them understand the reasons for attrition. According to 
officials, a common reason why staff leave the agency is limited 
promotion potential, particularly from the GS-12 or GS-13 levels into 
more senior positions. Another reason officials reported for attrition 
is that some employees have expertise or skill sets that are easily 
transferrable and in demand elsewhere, including within other HHS and 
federal agencies. In particular, officials noted that the skill sets 
of project officers and those with information technology backgrounds 
are highly sought elsewhere in the government. While exit interviews 
provide insight into why staff are leaving the agency, officials also 
reported that they use information from the Federal Employee Viewpoint 
Survey to get a sense of the number of staff considering leaving the 
agency in the next year.[Footnote 34] 

HRSA also tracks retirement eligibility at the agency, bureau, and 
office levels. Quarterly, HRSA receives agency-wide data from HHS on 
the proportion of staff, including supervisory staff, eligible to 
retire in the next 5 years. Additionally, in early 2013, HRSA 
officials began providing leaders in each bureau and office with the 
names and retirement eligibility dates of their staff who are eligible 
to retire within the next 5 years. HRSA officials indicated they plan 
to provide these data on an annual basis going forward; however, 
officials indicated that the retirement eligibility reports are of 
limited use to them because eligibility to retire does not mean that 
an employee actually plans to retire. 

To respond to retirements and other types of attrition, HRSA has 
instituted succession planning efforts which generally focus on 
providing leadership development to agency staff. In 2011, HRSA 
launched two agency-wide leadership development programs to help 
prepare staff to take on leadership roles when such opportunities 
arise. One of these programs, the Mid-Level Leadership Development 
Program, is for staff at the GS-12 and GS-13 levels and focuses on 
leadership skills development, interdepartmental project experience, 
exposure to HRSA leaders, and an understanding of HRSA's mission, 
challenges, and opportunities. The other program, the Administrative 
Management Development Program, focuses on individuals who are 
interested in careers handling the administrative management functions 
of the agency. HRSA officials indicated that, as of September 2013, 59 
staff had completed one of these two programs. According to HRSA 
officials, as of July 2013, the agency was in the process of 
developing two additional leadership development programs--one 
targeted to staff at the GS-11 level and below and another for staff 
at the GS-14 and GS-15 levels. Officials estimated these additional 
programs would become operational in fiscal year 2014. 

In addition to leadership development programs, HRSA officials said 
that there are several other opportunities for staff to gain 
leadership experience and professional development. For example, HRSA 
has established a mentoring program, which focuses on leadership 
development for both the participating mentor and mentee, and a 
coaching program, which provides participating supervisors and 
managers with opportunities to focus on specific areas for further 
development. Officials across the agency also promote opportunities 
for employees to be assigned to acting roles in more senior positions 
when there is a vacant position or when a supervisor is on leave. For 
example, if a branch chief were to retire or be out of the office for 
an extended period, a senior level employee in the branch may be asked 
to act as the branch chief until the position can officially be filled 
or the branch chief returns. HRSA officials indicated that they work 
to train individuals to enhance their capabilities, which may better 
position staff to be successful candidates when leadership positions 
open up in the agency. In addition, opportunities to serve in an 
acting capacity in a role more senior to their own allows employees to 
smoothly transition into a position should they be selected for it on 
a permanent basis. For example, HRSA officials we spoke with told us 
that when the Associate Administrator of one of the bureaus was 
recently promoted--leaving a key vacancy--the Deputy Associate 
Administrator served as Acting Associate Administrator until promoted 
into the position permanently. Leaders from some bureaus also noted 
additional bureau-specific succession planning efforts. For example, 
the HIV/AIDS Bureau created its Organizational Development Unit in 
fiscal year 2012 to help deal with staff attrition issues within the 
bureau by providing training, helping staff create individual 
development plans, and providing mentoring opportunities to encourage 
staff to stay and continue to grow professionally. 

HRSA officials told us they also promote cross-training opportunities 
among staff, where employees work on multiple programs to assure a 
broader range of knowledge so that they are able to take over for each 
other should someone leave the bureau or agency. For example, Office 
of Rural Health Policy leaders said that they have their staff work on 
multiple programs to ensure they obtain a broader range of skills than 
they would acquire by working on just one program. Similarly, they 
assign their policy staff to a lead and backup role on key regulations 
so that if one person leaves the organization or is out of the office 
for an extended period of time, another is also familiar with the 
topic and able to complete the review. HRSA officials noted that some 
of these succession planning efforts, such as leadership training, 
also help with staff retention. In addition, officials noted that they 
have other efforts in place to promote staff retention, such as 
employee recognition and morale boosting opportunities.[Footnote 35] 

HRSA Obligated Over $240 Million for Contracts in Fiscal Year 2012, 
the Majority of Which Were for Information Technology and Program 
Support: 

In fiscal year 2012, HRSA obligated over $240 million, or about 3 
percent of its appropriations, to contracts to acquire goods or 
services necessary to support its operations.[Footnote 36] With the 
exception of fiscal year 2008, when HRSA had approximately $167 
million in contract obligations, the amount of HRSA's contract 
obligations generally remained steady over the past 5 years. (See 
figure 9.) 

Figure 9: Amount of HRSA Contract Obligations, Fiscal Years 2008 
through 2012: 

[Refer to PDF for image: vertical bar graph] 

Fiscal Year     Adjusted Appropriation 

Fiscal year: 2008; 
Contract Obligations: $167.22 million. 

Fiscal year: 2009; 
Contract Obligations: $228.81 million. 

Fiscal year: 2010; 
Contract Obligations: $234.29 million. 

Fiscal year: 2011; 
Contract Obligations: $223.94 million. 

Fiscal year: 2012; 
Contract Obligations: $240.93 million. 

Source: GAO analysis of HRSA data. 

[End of figure] 

The vast majority of HRSA's fiscal year 2012 contract obligations 
(approximately 97 percent) were used to obtain services, while the 
remaining 3 percent of obligations went toward goods, such as computer 
software. Nearly 60 percent of HRSA's fiscal year 2012 contract 
obligations were for two categories of services: [Footnote 37] (1) 
information technology and telecommunications services, which includes 
HRSA's contract to support the operation and management of the 
agency's online system for documenting its grantee oversight 
activities, called the Electronic Handbook; and (2) professional 
support services, which includes HRSA's contracts for the provision of 
technical assistance, such as site visits, to grantees. (See table 2.) 

Table 2: HRSA Contract Obligations by Category, Fiscal Year 2012: 

Category: Information Technology and Telecommunications; 
Description: Covers contracts for the provision of information 
technology, including systems development, operations, and maintenance 
such as for HRSA's Electronic Handbook and the Vaccine Injury 
Compensation System; 
Amount of obligations[A]: $79,180,379; 
Percent of obligations[B]: 32.9%. 

Category: Professional Support; 
Description: Covers contracts that provide temporary support services, 
technical assistance for grantees, expert witnesses, evaluations, 
studies, and accounting assistance; 
Amount of obligations[A]: $62,031,355; 
Percent of obligations[B]: 25.8%. 

Category: Medical, Dental, and Surgical Services; 
Description: Covers contracts that provide critical medical functions 
such as care for individuals with leprosy through the National 
Hansen's Disease Program; 
Amount of obligations[A]: $34,170,271; 
Percent of obligations[B]: 14.2%. 

Category: Management Support; 
Description: Covers contracts that provide advertising, data 
collection, accounting, logistics, public relations, and procurement 
support; 
Amount of obligations[A]: $25,092,122; 
Percent of obligations[B]: 10.4%. 

Category: Special Studies and Analysis; 
Description: Covers contracts for analysis and studies to all of 
HRSA's programmatic bureaus for purposes other than research and 
development; 
Amount of obligations[A]: $12,586,780; 
Percent of obligations[B]: 5.2%. 

Category: Education and Training; 
Description: Covers contracts that provide curriculum development and 
training for HRSA employees, including grants management and other 
professional training; 
Amount of obligations[A]: $5,934,606; 
Percent of obligations[B]: 2.5%. 

Category: Automatic Data Processing Equipment, Software, Supplies and 
Support Equipment; 
Description: Covers the provision of information technology and 
telecommunication goods and services, such as scanners and records 
management services; 
Amount of obligations[A]: $5,869,453; 
Percent of obligations[B]: 2.4%. 

Category: Other; 
Description: Covers all other HRSA contract obligations for goods and 
services; 
Amount of obligations[A]: $16,068,292; 
Percent of obligations[B]: 6.7%. 

Source: GAO analysis of information from HRSA and the Federal 
Procurement Data System-Next Generation. 

[A] The amount of obligations we report accounts for any funds that 
were deobligated within the fiscal year; funds may be deobligated, for 
example, due to a reduction in costs or a correction to recorded 
amounts. 

[B] Due to rounding, percentages do not add to 100. 

[End of table] 

In fiscal year 2012, nearly 40 percent, or $95,697,751, of HRSA's 
contract obligations provided cross-cutting support, meaning that they 
were utilized by more than one HRSA organizational component. The 
remaining 60 percent of HRSA's obligations were for programs and 
activities specific to a single programmatic bureau, though the amount 
of obligations varied by bureau. (See table 3 for a summary of the 
amount of contract obligations by organizational component and 
appendix II for information on the contract with the highest 
obligation for each component.) 

Table 3: Amount of HRSA Contract Obligations by Organizational 
Component, Fiscal Year 2012: 

Organizational component: Bureau of Clinician Recruitment and Service; 
Amount of obligations[A]: $8,955,736; 
Percent of HRSA's obligations: 3.7%. 

Organizational component: Bureau of Health Professions; 
Amount of obligations[A]: $24,974,157; 
Percent of HRSA's obligations: 10.4%. 

Organizational component: Bureau of Primary Health Care; 
Amount of obligations[A]: $27,114,951; 
Percent of HRSA's obligations: 11.3%. 

Organizational component: Healthcare Systems Bureau[B]; 
Amount of obligations[A]: $63,633,813; 
Percent of HRSA's obligations: 26.4%. 

Organizational component: HIV/AIDS Bureau; 
Amount of obligations[A]: $7,770,125; 
Percent of HRSA's obligations: 3.2%. 

Organizational component: Maternal and Child Health Bureau; 
Amount of obligations[A]: $7,221,337; 
Percent of HRSA's obligations: 3.0%. 

Organizational component: Office of Rural Health Policy; 
Amount of obligations[A]: $5,565,386; 
Percent of HRSA's obligations: 2.3%. 

Organizational component: Cross-cutting[C]; 
Amount of obligations[A]: $95,697,751; 
Percent of HRSA's obligations: 39.7%. 

Organizational component: HRSA Total; 
Amount of obligations[A]: $240,933,256; 
Percent of HRSA's obligations: 100%. 

Source: GAO analysis of information from HRSA and the Federal 
Procurement Data System-Next Generation. 

[A] The amount of obligations we report accounts for any funds that 
were deobligated within the fiscal year; funds may be deobligated, for 
example, due to a reduction in costs or a correction to recorded 
amounts. 

[B] We have included contract obligations for the National Hansen's 
Disease Program--a program that provides care and treatment for 
individuals with leprosy and related conditions--with the data for the 
Healthcare Systems Bureau, since this bureau took oversight 
responsibility for this program in August 2012. Prior to that, the 
program was under the auspices of the Bureau of Primary Health Care. 

[C] Cross-cutting refers to contracts that were utilized by more than 
one HRSA organizational component. 

[End of table] 

HRSA's bureaus utilized contracts for different purposes. For example, 
nearly 78 percent of the Bureau of Health Profession's fiscal year 
2012 obligations were for information technology and 
telecommunications services, primarily for the National Practitioner 
Data Bank, while the Maternal and Child Health Bureau did not have any 
obligations for that purpose.[Footnote 38] Conversely, 69 percent of 
the Maternal and Child Health Bureau's obligations in fiscal year 2012 
were for professional services such as for a newborn hearing, 
screening, and intervention programs study, while about 12 percent of 
the Bureau of Health Professions' obligations were for professional 
services. See appendix III for information on the top categories of 
contracted services or goods by organizational component. 

According to HRSA officials, the agency uses contracts to support its 
operations for a variety of reasons, including to supplement HRSA 
staff because of time constraints, or to fulfill short-term needs. In 
addition, HRSA uses contracts to perform functions that require 
specialized skills for which HRSA staff do not have the appropriate 
expertise, such as clinical or financial expertise. For example, the 
Office of Rural Health Policy uses contract staff with special 
expertise in areas such as oral and primary health care to provide 
technical assistance to its broad range of grantees, while the Bureau 
of Primary Health Care uses contract staff with financial expertise to 
conduct site-visits to health center grantees, assist HRSA staff with 
understanding grantees' financial audits, and help grantees develop 
plans to improve their financial stability. Furthermore, according to 
HRSA officials, the agency uses contracts to support its operations 
when contract staff can perform the functions more efficiently and at 
a lower cost than HRSA staff. For instance, the Maternal and Child 
Health Bureau obtains logistical support services, such as supporting 
large advisory committee meetings, from a contractor because it is 
more efficient and cost effective than having bureau staff manage 
these functions. Finally, HRSA uses contracts for other reasons 
including when the agency is legislatively required to do so. For 
example, HRSA is required by law to contract with one or more entities 
to carry out certain aspects of its C.W. Bill Young Cell 
Transplantation Program, a program overseen by the Healthcare Systems 
Bureau related to cord blood, bone marrow, and transplantation. 
[Footnote 39] 

Agency Comments: 

We provided a draft of this report to HHS for its review. In its 
written comments, HHS noted that the report recognized the mechanisms 
HRSA has in place to ensure the coordinated flow of communication and 
plan for succession. (HHS comments are reprinted in appendix IV.) 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies of this report 
to the Secretary of Health and Human Services and the Administrator of 
HRSA. In addition, the report will be available on the GAO website 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 draperd@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 V. 

Signed by: 

Debra A. Draper: 
Director, Health Care: 

List of Requesters: 

The Honorable Lamar Alexander: 
Ranking Member: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

The Honorable Tom Coburn: 
Ranking Member: 
Committee on Homeland Security and Governmental Affairs: 
United States Senate: 

The Honorable Michael B. Enzi: 
Ranking Member: 
Subcommittee on Children and Families: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

The Honorable Richard Burr: 
Ranking Member: 
Subcommittee on Primary Health and Aging: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

[End of section] 

Appendix I: Health Resources and Services Administration's (HRSA) 
Programs by Programmatic Bureau, Fiscal Year 2013: 

Bureau of Clinician Recruitment and Service: 

Programs: Faculty Loan Repayment Program; 
Description: Bureau of Clinician Recruitment and Service: Provides 
individuals from disadvantaged backgrounds with an eligible health 
professions degree (e.g., dentistry, physician assistant) 
opportunities to serve as faculty members in an accredited and 
eligible health professions school for a minimum of two years. For 
each year of service, participants are awarded up to $30,000 for their 
educational loans. 

Programs: Health Professional Shortage Areas (HPSAs); 
Description: Bureau of Clinician Recruitment and Service: Designates 
federal HPSAs (areas in which there may be a shortage of primary 
medical care, dental, or mental health providers), Medically 
Underserved Areas (areas in which residents have a shortage of 
personal health services), and Medically Underserved Populations 
(which may include groups of persons who face economic, cultural, or 
linguistic barriers to health care). Shortage designations are used to 
prioritize HRSA's health professional scholarship and loan repayment 
programs and other federal and state programs. 

Programs: National Health Service Corps; 
Description: Bureau of Clinician Recruitment and Service: Offers 
assistance to HPSAs in every U.S. state and territory to recruit and 
retain qualified primary care providers by providing scholarships or 
loan repayments to individuals who agree to provide services in 
shortage areas. 

Programs: Native Hawaiian Health Scholarship Program; 
Description: Bureau of Clinician Recruitment and Service: Supports the 
demand for more health care professionals to deliver primary health 
services to Native Hawaiians in the State of Hawaii by providing 
scholarships in return for a commitment to serve in designated areas 
for a specified time period. 

Programs: NURSE Corps; 
Description: Bureau of Clinician Recruitment and Service: Alleviates 
the shortage of nurses and economic barriers that may be associated 
with pursuing a career in nursing or teaching as nurse faculty by 
offering loan repayment assistance to registered nurses in return for 
a commitment to serve as a nurse in a critical shortage facility (in 
designated HPSAs) or as nurse faculty at an accredited eligible school 
of nursing, and offering scholarships to nursing students in return 
for service in a critical shortage facility. 

Programs: Primary Care Offices; 
Description: Bureau of Clinician Recruitment and Service: In 
partnership with HRSA's Bureau of Primary Health Care, this program 
supports cooperative agreements with 54 State Primary Care Offices and 
territorial agencies to facilitate the coordination of activities such 
as needs assessments and technical assistance within a state that 
relate to the delivery of primary care services, and the recruitment 
and retention of critical health providers. 

Bureau of Health Professions: 

Programs: Advanced Nursing Education Program; 
Description: Bureau of Clinician Recruitment and Service: Provides 
infrastructure grants to schools to build and enhance advanced nursing 
education programs, and two traineeships--the Advanced Education in 
Nursing Traineeship and the Nurse Anesthetist Traineeship. In 
addition, the Advanced Nursing Education Expansion Program provides 
grants to schools of nursing to accelerate the production of primary 
care advanced practice nurses. 

Programs: Area Health Education Centers; 
Description: Bureau of Clinician Recruitment and Service: Promotes a 
national role in addressing health care workforce shortages, 
particularly in the areas of health career awareness and 
interdisciplinary and interprofessional community-based primary care 
training. 

Programs: Centers of Excellence; 
Description: Bureau of Clinician Recruitment and Service: Supports 
activities to enhance the academic performance of underrepresented 
minority students, support underrepresented minority faculty 
development, and facilitate research on minority health issues. 

Programs: Children's Hospitals Graduate Medical Education Payment 
Program; 
Description: Bureau of Clinician Recruitment and Service: Supports 
graduate medical education and training of residents and fellows in 
freestanding children's teaching hospitals and enhances the supply of 
primary care and pediatric medical and surgical subspecialties. 

Programs: Comprehensive Geriatric Education; 
Description: Bureau of Clinician Recruitment and Service: Provides 
support to train and educate individuals who provide geriatric care 
for the elderly. 

Programs: Geriatric Programs; 
Description: Bureau of Clinician Recruitment and Service: Improves 
access to quality health care to the elderly through a range of 
programs that focus on increasing the number of geriatric specialists 
and increasing geriatrics competencies in the generalist workforce 
through education and training to improve care. 

Programs: Health Care Workforce Assessment; 
Description: Bureau of Clinician Recruitment and Service: Collects and 
analyzes health workforce data and information through the National 
Center for Health Workforce Analysis (National Center) in order to 
provide national and state policy makers and the private sector with 
information on health workforce supply, demand, and needs. The 
National Center also evaluates workforce policies and programs as to 
their effectiveness in addressing workforce issues. 

Programs: Health Careers Opportunity Program; 
Description: Bureau of Clinician Recruitment and Service: Supports 
activities for kindergarten through 12th grade, baccalaureate, post-
baccalaureate, and graduate students to improve the recruitment and 
enhance the academic preparation of students from disadvantaged 
backgrounds into the health professions. 

Programs: Mental and Behavioral Health Education and Training; 
Description: Bureau of Clinician Recruitment and Service: Works to 
close the gap in access to mental and behavioral health care services 
by increasing the number of adequately prepared mental and behavioral 
health and substance abuse providers. 

Programs: National Practitioner Data Bank; 
Description: Bureau of Clinician Recruitment and Service: Serves as a 
flagging system intended to prompt a comprehensive review of health 
care practitioners' licensure activity, medical malpractice payment 
history and record of clinical privileges. Used in conjunction with 
information from other sources, the National Practitioner Data Bank 
assists in promoting quality health care, and deterring fraud and 
abuse in the health care delivery system. 

Programs: Nurse Education, Practice, Quality and Retention Program; 
Description: Bureau of Clinician Recruitment and Service: Supports 
initiatives to expand the nursing pipeline, promote career mobility, 
enhance nursing practice, provide continuing education, and support 
retention. 

Programs: Nurse Faculty Loan Program; 
Description: Bureau of Clinician Recruitment and Service: Supports the 
establishment and operation of a loan fund within participating 
schools of nursing to assist nurses in completing their graduate 
education to become qualified nurse faculty. 

Programs: Nursing Workforce Diversity; 
Description: Bureau of Clinician Recruitment and Service: Increases 
nursing education opportunities for individuals from disadvantaged 
backgrounds, including racial and ethnic minorities underrepresented 
among registered nurses, by providing student stipends and 
scholarships. 

Programs: Oral Health Training Programs; 
Description: Bureau of Clinician Recruitment and Service: Includes a 
range of programs designed to increase access to culturally competent, 
high quality dental health services to rural and other underserved 
communities by increasing the number of oral health care providers and 
improving the training programs for oral health care providers. 

Programs: Primary Care Training and Enhancement; 
Description: Bureau of Clinician Recruitment and Service: Supports and 
develops primary care physician and physician assistant training 
programs. 

Programs: Public Health and Preventative Medicine Program; 
Description: Bureau of Clinician Recruitment and Service: Supports 
activities that train public health and preventive medicine students, 
residents, and professionals to enhance the supply and expertise of 
the public health workforce. 

Programs: Scholarships for Disadvantaged Students; 
Description: Bureau of Clinician Recruitment and Service: Increases 
diversity in the health professions and nursing workforce by providing 
grants to eligible professions and nursing schools for use in awarding 
scholarships to students from disadvantaged backgrounds with financial 
need, many of whom are underrepresented minorities. 

Programs: Teaching Health Centers Graduate Medical Education Payment 
Program; 
Description: Bureau of Clinician Recruitment and Service: Provides 
Graduate Medical Education payments to support community-based 
training by covering the costs of resident training in community-based 
ambulatory primary care settings, such as health centers, and 
bolstering the primary care workforce. 

Bureau of Primary Health Care: 

Programs: Free Clinics Medical Malpractice; 
Description: Bureau of Clinician Recruitment and Service: Provides 
medical malpractice protection at sponsoring health clinics to 
encourage health care providers to volunteer their time at free 
clinics, thus expanding the capacity of the health care safety net. 

Programs: Health Center Capital Development Program; 
Description: Bureau of Clinician Recruitment and Service: Supports the 
construction and renovation of health centers. 

Programs: Health Center Federal Tort Claims Program; 
Description: Bureau of Clinician Recruitment and Service: The Health 
Center Program administers the Federal Tort Claims Act program, under 
which employees of eligible health centers may be deemed to be federal 
employees qualified for malpractice coverage under the Federal Tort 
Claims Act. 

Programs: Health Center Program; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to eligible health centers to deliver comprehensive, high-
quality, cost-effective primary health care to patients regardless of 
their ability to pay. 

Programs: School-Based Health Center Facilities; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants for the establishment of school-based health centers; 
grant funds can be used for expenditures for facilities, equipment, or 
similar expenditures. 

Healthcare Systems Bureau[A]: 

Programs: 340B Drug Pricing Program; 
Description: Bureau of Clinician Recruitment and Service: Requires 
drug manufacturers to provide discounts or rebates to a specified set 
of HHS-assisted programs and hospitals that meet the criteria in the 
Public Health Service Act and the Social Security Act for serving a 
disproportionate share of low-income patients. 

Programs: Countermeasures Injury Compensation Program; 
Description: Bureau of Clinician Recruitment and Service: Provides 
compensation to individuals for serious physical injuries or deaths 
from pandemic, epidemic, or security countermeasures. 

Programs: C.W. Bill Young Cell Transplantation Program; 
Description: Bureau of Clinician Recruitment and Service: Attempts to 
increase the number of transplants for recipients suitably matched to 
biologically unrelated donors of bone marrow and cord blood. 

Programs: National Hansen's Disease Program[B]; 
Description: Bureau of Clinician Recruitment and Service: Provides 
care and treatment for Hansen's Disease (leprosy) and related 
conditions to any patient living in the United States or Puerto Rico 
through direct patient care at its facilities in Louisiana, through 
grants to an inpatient program in Hawaii, by contracting with 11 
regional outpatient clinics, and providing payments to the State of 
Hawaii for hospital and clinic facilities at Kalaupapa, Molokai, and 
Honolulu. Also provides for the renovation and modernization of the 
Louisiana facilities to eliminate structural deficiencies and keep 
with accepted standards of safety, comfort, human dignity, efficiency, 
and effectiveness. 

Programs: National Cord Blood Inventory; 
Description: Bureau of Clinician Recruitment and Service: Works on 
building a genetically and ethnically diverse inventory of high-
quality umbilical cord blood for transplantation. 

Programs: National Vaccine Injury Compensation Program; 
Description: Bureau of Clinician Recruitment and Service: Provides 
compensation to people found to be injured by certain vaccines given 
routinely to children and adults, such as seasonal flu vaccine, 
measles, mumps, rubella, or polio. 

Programs: Organ Transplantation; 
Description: Bureau of Clinician Recruitment and Service: Attempts to 
extend and enhance the lives of individuals with end-stage organ 
failure for whom an organ transplant is the most appropriate 
therapeutic treatment by providing a national system to allocate and 
distribute donor organs to individuals waiting for an organ transplant. 

Programs: Poison Control Program; 
Description: Bureau of Clinician Recruitment and Service: Funds poison 
centers; maintains a single, national toll-free number to ensure 
universal access to poison center services and connect callers to the 
poison center serving their area; and implements a nationwide media 
campaign to educate the public and health care providers about poison 
prevention, poison center services, and the toll-free number. 

HIV/AIDS Bureau: 

Programs: Ryan White HIV/AIDS CARE Act Program Part A-Emergency Relief; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to metropolitan areas experiencing the greatest burdens of the 
country's human immunodeficiency virus and acquired immunodeficiency 
syndrome (HIV/AIDS) epidemic, and provide those communities with 
resources they need to confront the highly concentrated epidemic 
within the jurisdiction. 

Programs: Ryan White HIV/AIDS CARE Act Program Part B-Comprehensive 
Care: HIV Care Grants to States and the AIDS Drug Assistance Program; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to all 50 states, the District of Columbia, Puerto Rico, the 
U.S. Virgin Islands, Guam and 5 U.S. Pacific Territories or Associated 
Jurisdictions to provide services for people living with HIV/AIDS. The 
AIDS Drug Assistance Program supports the provision of HIV medications 
and related services. 

Programs: Ryan White HIV/AIDS CARE Act Program Part C-Early 
Intervention Services; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to 344 community and faith-based primary health clinics and 
public health providers in 49 states, Puerto Rico, the District of 
Columbia, and the U.S. Virgin Islands for targeting HIV medical 
services to underserved and uninsured people living with HIV/AIDS in 
specific geographic communities, including rural and frontier 
communities. 

Programs: Ryan White HIV/AIDS CARE Act Program Part D-Women, Infants, 
Children, and Youth; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to public or private nonprofit entities that provide or arrange 
for primary care and support services for HIV-positive women, infants, 
children, and youth. 

Programs: Ryan White HIV/AIDS CARE Act Program Part F-AIDS Education 
and Training Centers; 
Description: Bureau of Clinician Recruitment and Service: Funds the 
AIDS Education and Training Centers--a network of 11 regional centers 
with more than 130 local performance sites and five national centers--
that offers specialized clinical education and consultation on 
HIV/AIDS transmission, treatment, and prevention to front-line health 
care providers. 

Programs: Ryan White HIV/AIDS CARE Act Program Part F-Dental 
Reimbursement Program; 
Description: Bureau of Clinician Recruitment and Service: Provides 
access to oral health care for people living with HIV/AIDS by 
reimbursing dental education programs for the unreimbursed costs 
associated with providing care to people with HIV and by working with 
partners to provide education and clinical training for dental care 
providers, especially those in community-based settings. 

Programs: President's Emergency Plan for AIDS Relief; 
Description: Bureau of Clinician Recruitment and Service: Although 
overseen by multiple federal agencies, the HIV/AIDS Bureau manages 
HRSA's contributions to this program whose mission is to deliver 
HIV/AIDS care and treatment and helps build sustainable health systems 
so that host countries can confront their epidemics in the future. 

Programs: Special Projects of National Significance; 
Description: Bureau of Clinician Recruitment and Service: Supports the 
development of innovative models of HIV care to quickly respond to the 
emerging needs of clients served by the Ryan White HIV/AIDS CARE Act 
Program by evaluating the effectiveness of the models' design, 
implementation, utilization, cost, and health-related outcomes, and 
promoting the dissemination and replication of successful models. 

Maternal and Child Health Bureau: 

Programs: Autism and Other Developmental Disorders; 
Description: Bureau of Clinician Recruitment and Service: Under the 
auspices of the Combating Autism Act of 2006, this program supports 
activities to provide information and education to increase public 
awareness, promote research into the development and validation of 
screening tools and interventions, promote early learning of 
individuals at higher risk, increase the number of individuals who are 
able to confirm or rule out a diagnosis, and increase the number of 
individuals able to provide evidence-based interventions for autism 
spectrum disorders or other developmental disabilities. 

Programs: Emergency Medical Services for Children; 
Description: Bureau of Clinician Recruitment and Service: Focuses on 
generating evidence on best practices regarding pediatric emergency 
care as well as direct outreach to the states, territories, and the 
District of Columbia to implement these best practices. 

Programs: Family to Family Health Information Centers; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants funded by the Patient Protection and Affordable Care Act to 
family-staffed, family-run organizations to ensure families have 
access to adequate information about health care, community resources, 
and support in order to make informed decisions around their 
children's health care. 

Programs: Healthy Start; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to communities with exceptionally high rates of infant 
mortality to reduce disparities in access to and utilization of health 
services, improve the quality of the local health care system, empower 
women and their families, and increase consumer and community voices 
and participation in health care decisions. 

Programs: Heritable Disorders; 
Description: Bureau of Clinician Recruitment and Service: Works to 
improve the ability of states to provide newborn and child screening 
for heritable (genetic) disorders. 

Programs: James T. Walsh Universal Newborn Hearing Screening; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to support the physiologic testing of newborn infants prior to 
their hospital discharge; audiologic evaluation by three months of age; 
and entry into a program of early intervention by six months of age 
with linkages to a medical home and family-to-family support. 

Programs: Maternal and Child Health Block Grant; 
Description: Bureau of Clinician Recruitment and Service: Aims to 
improve the health of all mothers, children, and their families to 
reduce health disparities, improve access to health care, and improve 
the quality of health care. The program has three components: (1) 
block grant funds to states distributed by formula; (2) Special 
Projects of Regional and National Significance which supports a 
variety of projects in research, training, screening, and other 
services; and (3) Community Integrated Service Systems which supports 
projects that seek to increase the capacity for service delivery at 
the local level and to foster formation of comprehensive, integrated, 
community level service systems for mothers and children.[C]. 

Programs: Maternal, Infant, and Early Childhood Home Visiting Program; 
Description: Bureau of Clinician Recruitment and Service: Collaborates 
with the Administration for Children and Families to improve 
coordination of services for at-risk communities, to identify and 
provide comprehensive services to improve outcomes for families who 
reside in at-risk communities, and to strengthen and improve the 
programs and activities carried out under the Maternal and Child 
Health Block Grant program.[D]. 

Programs: Sickle Cell Service Demonstrations; 
Description: Bureau of Clinician Recruitment and Service: Develops 
systemic mechanisms for the treatment of sickle cell disease and the 
prevention of morbidity and mortality associated with the condition. 

Programs: Traumatic Brain Injury; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to (1) fund the development and implementation of statewide 
systems that ensure access to comprehensive and coordinated traumatic 
brain injury services including: transitional service, rehabilitation, 
education and employment, and long-term community support; 
and (2) provide services such as referrals, advice, and legal 
representation to individuals with traumatic brain injury. 

Office of Rural Health Policy: 

Programs: Black Lung; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to public and private entities, including faith-based and 
community-based organizations, to establish and operate clinics that 
provide for the outreach and education, diagnosis, treatment, 
rehabilitation, and benefits counseling of active and retired coal 
miners and others with occupation-related respiratory and pulmonary 
impairments. 

Programs: Radiation Exposure Screening and Education Program; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to states, local governments, and appropriate health care 
organizations to support programs for cancer screening for individuals 
adversely affected by the mining, transport, and processing of 
uranium, and the testing of nuclear weapons for the nation's weapons 
arsenal. 

Programs: Rural and Community Access to Emergency Devices; 
Description: Bureau of Clinician Recruitment and Service: Provides 
funds to community partnerships, which then purchase and distribute 
automatic external defibrillators to be placed in rural communities 
and train emergency first responders to use the devices. 

Programs: Rural Health Care Services, Outreach, Network, and Quality 
Improvement Grants; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to improve access to care, coordination of care, integration of 
services, and focus on quality improvement in rural communities. 

Programs: Rural Health Policy Development; 
Description: Bureau of Clinician Recruitment and Service: Supports a 
range of policy analysis, research, and information dissemination for 
the Office of Rural Health Policy. 

Programs: Rural Hospital Flexibility Grants; 
Description: Bureau of Clinician Recruitment and Service: Supports a 
range of activities focusing primarily on Critical Access Hospitals 
through three grant programs: (1) the Medicare Rural Hospital 
Flexibility (Flex) Grant Program; (2) Small Hospital Improvement 
Program; and (3) the Flex Rural Veterans Health Access Program.[E]. 

Programs: State Offices of Rural Health; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants to states to establish and maintain State Offices of Rural 
Health. 

Programs: Telehealth[F]; 
Description: Bureau of Clinician Recruitment and Service: Provides 
grants that support telehealth technologies through the following 
three programs: (1) Telehealth Network Grant Program, which provides 
funding for pilot projects to examine the cost impact and value-added 
from telehome care and tele-monitoring services and activities such as 
chronic disease management and distance learning; (2) Telehealth 
Resource Center Grant Program, which provides technical assistance to 
communities wishing to establish telehealth services; and (3) 
Licensure Portability Grant Program, which assists states to improve 
clinical licensure coordination across state lines. 

Source: GAO summary of information from HRSA. 

[A] As of April 2013, the Healthcare Systems Bureau managed two 
programs that no longer receive funding: (1) the Health Care and Other 
Facilities Program, which provided grants for new construction, 
renovation, design development and equipment to hospitals, community 
health centers, universities, and research centers; and (2) the Hill-
Burton Loan Guarantee and Project Grant Program which provided loan 
guarantees and grants to facilities for construction. Although these 
programs were not funded in fiscal year 2012, HRSA officials told us 
that they continue to monitor recipients of prior years funding under 
these programs. 

[B] The Healthcare Systems Bureau took oversight responsibility for 
this program in August 2012. Prior to that, the program was under the 
auspices of the Bureau of Primary Health Care. 

[C] A block grant is a type of grant where funding recipients have 
substantial discretion over the type of activities to support, with 
minimal federal administrative requirements or restrictions. 

[D] At-risk communities are communities with concentrations of (1) 
premature birth, low-birth weight infants, and infant mortality, or 
other indicators of at-risk prenatal, maternal, newborn or child 
health; (2) poverty; (3) crime; (4) domestic violence; (5) high-school 
drop outs; (6) substance abuse; (7) unemployment; or (8) child 
maltreatment. 

[E] Critical Access Hospitals are small, rural hospitals. To be 
certified as a Critical Access Hospital a facility must meet certain 
criteria, including being located in a rural area, having no more than 
25 inpatient beds, and furnishing 24-hour emergency care services 7 
days a week. 

[F] Telehealth is the use of electronic information and 
telecommunications technologies to support long distance health care, 
patient and professional health related education, public health, and 
health administration. 

[End of table] 

[End of section] 

Appendix II: HRSA Contracts with the Highest Total Amount of 
Obligations by Organizational Component, Fiscal Year 2012: 

Organizational component: Bureau of Clinician Recruitment and Service; 
Purpose of contract with the highest total amount of obligations in 
fiscal year 2012: Provides travel, relocation, and logistical support 
to relocate health care providers for the National Health Service 
Corps; 
Amount of contract obligations[A]: $4,376,546; 
Percent of total HRSA contract obligations: 1.8%. 

Organizational component: Bureau of Health Professions; 
Purpose of contract with the highest total amount of obligations in 
fiscal year 2012: Provides services to maintain, update, and enhance 
the National Practitioner Data Bank; 
Amount of contract obligations[A]: $9,186,026; 
Percent of total HRSA contract obligations: 3.8%. 

Organizational component: Bureau of Primary Health Care; 
Purpose of contract with the highest total amount of obligations in 
fiscal year 2012: Provides supplemental expert assistance and support 
to health center grantees and federal staff by providing technical and 
consultative assistance through site visits, documentation reviews, 
and consultations to new and existing grantees; 
Amount of contract obligations[A]: $13,356,664; 
Percent of total HRSA contract obligations: 5.5%. 

Organizational component: Healthcare Systems Bureau[B]; 
Purpose of contract with the highest total amount of obligations in 
fiscal year 2012: Establishes and maintains the National Bone Marrow 
Coordinating Center; 
Amount of contract obligations[A]: $16,048,000; 
Percent of total HRSA contract obligations: 6.7%. 

Organizational component: HIV/AIDS Bureau; 
Purpose of contract with the highest total amount of obligations in 
fiscal year 2012: Provides technical assistance for the Ryan White 
HIV/AIDS CARE Act Program; 
Amount of contract obligations[A]: $2,480,090; 
Percent of total HRSA contract obligations: 1.0%. 

Organizational component: Maternal and Child Health Bureau; 
Purpose of contract with the highest total amount of obligations in 
fiscal year 2012: Operates the Maternal, Infant, and Early Childhood 
Home Visiting Program Technical Assistance Coordinating Center; 
Amount of contract obligations[A]: $2,580,000; 
Percent of total HRSA contract obligations: 1.1%. 

Organizational component: Office of Rural Health Policy; 
Purpose of contract with the highest total amount of obligations in 
fiscal year 2012: Provides technical assistance for grantee programs 
to expand access to, coordinate, restrain the cost of, and improve the 
quality of health care through the development of health care networks 
in rural areas and regions; 
Amount of contract obligations[A]: $1,899,426; 
Percent of total HRSA contract obligations: 0.8%. 

Organizational component: Cross-Cutting[C]; 
Purpose of contract with the highest total amount of obligations in 
fiscal year 2012: Supports development, maintenance, and enhancement 
efforts for HRSA's Electronic Handbook, the agency's online system for 
documenting its grantee oversight activities, by integrating new 
business processes into the Electronic Handbook or integrating the 
Electronic Handbook with other existing systems; 
Amount of contract obligations[A]: $27,791,403; 
Percent of total HRSA contract obligations: 11.5%. 

Source: GAO analysis of information from HRSA and the Federal 
Procurement Data System-Next Generation. 

[A] The amount of obligations we report accounts for any funds that 
were deobligated within the fiscal year; funds may be deobligated, for 
example, due to a reduction in costs or a correction to recorded 
amounts. 

[B] We have included contract data for the National Hansen's Disease 
Program with the data for the Healthcare Systems Bureau, as this 
bureau took oversight responsibility for this program in August 2012. 
Prior to that, the program was under the auspices of the Bureau of 
Primary Health Care. 

[C] Cross-cutting refers to contracts that were utilized by more than 
one HRSA organizational component. 

[End of table] 

[End of section] 

Appendix III: Top Three Products or Services Obtained through 
Contracts by Organizational Component, Fiscal Year 2012: 

Organizational component: Bureau of Clinician Recruitment and Service; 

Top products or services obtained through contracts: 
1. Management Support; 
Percent of component's contract obligations: 48.9%. 

Top products or services obtained through contracts: 
2. Education and Training; 
Percent of component's contract obligations: 17.6%. 

Top products or services obtained through contracts: 
3. Professional Support; 
Percent of component's contract obligations: 17.4%. 

Organizational component: Bureau of Health Professions; 

Top products or services obtained through contracts: 
1. Information Technology and Telecommunications; 
Percent of component's contract obligations: 77.5%. 

Top products or services obtained through contracts: 
2. Professional Support; 
Percent of component's contract obligations: 12.2%. 

Top products or services obtained through contracts: 
3. Special Studies and Analysis; 
Percent of component's contract obligations: 4.5%. 

Organizational component: Bureau of Primary Health Care; 

Top products or services obtained through contracts: 
1. Professional Support; 
Percent of component's contract obligations: 72.4%. 

Top products or services obtained through contracts: 
2. Special Studies and Analysis; 
Percent of component's contract obligations: 22.4%. 

Top products or services obtained through contracts: 
3. Information Technology and Telecommunications; 
Percent of component's contract obligations: 3.4%. 

Organizational component: Healthcare Systems Bureau[A]; 

Top products or services obtained through contracts: 
1. Medical, Dental, and Surgical Services; 
Percent of component's contract obligations: 53.7%. 

Top products or services obtained through contracts: 
2. Management Support; 
Percent of component's contract obligations: 11.3%. 

Top products or services obtained through contracts: 
3. Professional Support; 
Percent of component's contract obligations: 10.7%. 

Organizational component: HIV/AIDS Bureau; 

Top products or services obtained through contracts: 
1. Professional Support; 
Percent of component's contract obligations: 48.6%. 

Top products or services obtained through contracts: 
2. Information Technology and Telecommunications; 
Percent of component's contract obligations: 28.5%. 

Top products or services obtained through contracts: 
3. Management Support; 
Percent of component's contract obligations: 12.7%. 

Organizational component: Maternal and Child Health Bureau; 

Top products or services obtained through contracts: 
1. Professional Support; 
Percent of component's contract obligations: 69.0%. 

Top products or services obtained through contracts: 
2. Management Support; 
Percent of component's contract obligations: 21.6%. 

Top products or services obtained through contracts: 
3. Administrative Support Services; 
Percent of component's contract obligations: 10.4%. 

Organizational component: Office of Rural Health Policy; 

Top products or services obtained through contracts: 
1. Professional Support; 
Percent of component's contract obligations: 95.1%. 

Top products or services obtained through contracts: 
2. Management Support; 
Percent of component's contract obligations: 4.7%. 

Top products or services obtained through contracts: 
3. Administrative Support Services; 
Percent of component's contract obligations: 0.1%. 

Organizational component: Cross-Cutting[B]; 

Top products or services obtained through contracts: 
1. Information Technology and Telecommunications; 
Percent of component's contract obligations: 54.1%. 

Top products or services obtained through contracts: 
2. Professional Support; 
Percent of component's contract obligations: 17.7%. 

Top products or services obtained through contracts: 
3. Management Support; 
Percent of component's contract obligations: 9.9%. 

Source: GAO Analysis of information from HRSA and the Federal 
Procurement Data System-Next Generation. 

[A] We have included contract data for the National Hansen's Disease 
Program with the data for the Healthcare Systems Bureau, as this 
bureau took oversight responsibility for this program in August 2012. 
Prior to that, the program was under the auspices of the Bureau of 
Primary Health Care. 

[B] Cross-cutting refers to contracts that were utilized by more than 
one HRSA organizational component. 

[End of table] 

[End of section] 

Appendix IV: Comments from the Department of Health and Human Services: 

Department of Health & Human Services: 
Office of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

November 8, 2013: 

Debra A. Draper: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Ms. Draper, 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) report entitled, "Health Resources and Services Administration: 
Review of Communication Mechanisms, Staffing, and Use of Contracts" 
(GAO-14-52). 

The Department appreciates the opportunity to review this report prior 
to publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled, 
"Health Resources And Services Administration: Review Of Communication 
Mechanisms, Staffing, And Use Of Contracts" (GAO-14-52): 

The Department appreciates the opportunity to review and comment on 
this draft report. 

HHS is pleased to note GAO's recognition of the mechanisms HRSA has in 
place to ensure the coordinated flow of communication both up and 
clown the organizational hierarchy as well as across the agency. HHS 
is also pleased to note GAO's recognition of HRSA's succession 
planning efforts, including the leadership development programs, 
mentoring programs and coaching programs that are in place and that 
will be continually evaluated and enhanced. 

As noted in this draft report, HRSA fulfills an extremely important 
role in improving access to health care services for people who are 
uninsured, isolated, or medically vulnerable. HRSA will continue to 
work to improve its internal processes. HRSA remains committed to 
their core management philosophy to ensure maximum impact of every 
dollar the public has entrusted to them. HRSA will also continue to 
value constructive criticism from outside sources, like GAO, to assist 
in their continuous cycle of evaluation and improvement. 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Debra A. Draper, (202) 512-7114 or draperd@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Michelle B. Rosenberg, 
Assistant Director; Jill K. Center; Kathleen Diamond; Cathleen J. 
Hamann; Julia Kennon; Emily Loriso; Rebecca Shea; and Jennifer M. 
Whitworth made key contributions to this report. 

[End of section] 

Footnotes: 

[1] Pub. L. No.111-5, 123 Stat. 115 (2009). 

[2] Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the 
Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-
152, 124 Stat. 1029 (2010). In this report, references to PPACA 
include amendments made by the Health Care and Education 
Reconciliation Act. 

[3] While ARRA and PPACA provided additional funding to HRSA, the 
annual appropriation made to the agency was reduced during some of 
these years. 

[4] Sequestration refers to mandated budget caps for federal agencies 
established by the Budget Control Act of 2011, Pub. Law No. 112-25, 
125 Stat. 240 (2011), which amended the Balanced Budget and Emergency 
Deficit Control Act of 1985, Pub. L. No. 99-177, 99 Stat. 1037 (1985), 
and reinstated caps on discretionary budget authority. These caps 
subsequently were amended by the American Taxpayer Relief Act of 2012, 
Pub. L. No. 112-240, 126 Stat. 2313 (2013). 

[5] See GAO, Drug Pricing: Manufacturer Discounts in the 340B Program 
Offer Benefits, but Federal Oversight Needs Improvement, [hyperlink, 
http://www.gao.gov/products/GAO-11-836] (Washington, D.C.: Sept. 23, 
2011). 

[6] See GAO, Ryan White CARE Act: Improvements Needed in Oversight of 
Grantees, [hyperlink, http://www.gao.gov/products/GAO-12-610] 
(Washington, D.C.: June 11, 2012). 

[7] See GAO, Health Center Program: Improved Oversight Needed to 
Ensure Grantee Compliance with Requirements, [hyperlink, 
http://www.gao.gov/products/GAO-12-546] (Washington, D.C.: May 29, 
2012). 

[8] We have additional work underway to review HRSA's management of 
the staff and contractors who have responsibility for overseeing 
grantees. 

[9] See GAO, Standards for Internal Control in the Federal Government, 
[hyperlink, http://www.gao.gov/products/GAO/AMID-00-21.3.1] 
(Washington, D.C.: Nov. 1, 1999). 

[10] HRSA has employees who are members of the U.S. Public Health 
Service Commissioned Corps (referred to in this report as Commissioned 
Corps), which is a part of HHS and fills essential public health 
leadership and service roles in federal government agencies and 
programs. Commissioned Corps officers are paid through a different pay 
plan than employees under the civilian pay plans. 

[11] We excluded student interns and staff with intermittent temporary 
schedules from our analysis due to the transient nature of their 
employment. Headquarters staff were those in the DC-Metro locality pay 
area; employees in all other locality pay areas were designated as 
regional staff. Organizational component codes were used to identify 
the bureau or office an employee was assigned to within HRSA. 

[12] We used the 2-year "onboard" average as the base population of 
"onboard" staff in a particular year to calculate attrition. These 
calculations include anyone who left HRSA, including those who left 
HRSA for jobs with other agencies within HHS. To identify individuals 
who left HRSA to go to another HHS agency, we tracked HRSA staff over 
the time period of our review and counted individuals whose agency 
changed from HRSA to another HHS agency as a departure due to 
resignation. 

[13] Our analysis of retirement eligibility is limited to career 
permanent employees. To calculate retirement eligibility, we computed 
the date at which the employee would be eligible for voluntary 
retirement at an unreduced annuity using age at hire, years of 
service, birth date, and retirement plan coverage. 

[14] See GAO, A Model of Strategic Human Capital Management, 
[hyperlink, http://www.gao.gov/products/GAO-02-373SP] (Washington, 
D.C.: Mar. 15, 2002). 

[15] HRSA defines this goal as ensuring leadership continuity and 
instilling leadership skills to support the agency's mission. 

[16] Grants constitute one form of federal assistance consisting of 
payments in cash or in kind to a state or local government or a 
nongovernmental recipient for a specified purpose. Cooperative 
agreements are another form of financial assistance similar to grants, 
but where the federal agency is more involved with the recipient 
during the performance of the project. HRSA also has programs that 
offer scholarships to students and educational loan repayment to 
health care providers in exchange for a commitment to provide care in 
underserved areas or for underserved populations. 

[17] A block grant is a type of grant where funding recipients have 
substantial discretion over the type of activities to support, with 
minimal federal administrative requirements or restrictions. 

[18] Under the Home Visiting Program, at-risk communities are 
communities with concentrations of (1) premature birth, low-birth 
weight infants, and infant mortality, or other indicators of at-risk 
prenatal, maternal, newborn or child health; (2) poverty; (3) crime; 
(4) domestic violence; (5) high-school drop outs; (6) substance abuse; 
(7) unemployment; or (8) child maltreatment. 

[19] The GS system is a classification and pay system for the majority 
of civilian federal employees. The GS system has 15 grades--GS-1 
(lowest) to GS-15 (highest). SES positions are federal employee 
positions that are classified above GS-15. Other government pay plans 
for which HRSA has staff include the federal wage system for hourly, 
blue collar employees and a pay plan for physicians and dentists. 

[20] Throughout this report, we use the term "bureaus" to refer to the 
seven organizational components that carry out the agency's 
programmatic work: Bureau of Clinician Recruitment and Service, Bureau 
of Health Professions, Bureau of Primary Health Care, Healthcare 
Systems Bureau, HIV/AIDS Bureau, Maternal and Child Health Bureau, and 
the Office of Rural Health Policy. HRSA considers the Office of Rural 
Health Policy to be similar in function and organizational structure 
to the six units with "bureau" in their titles. 

[21] Pub. L. No. 111-148, § 3509(a), 124 Stat. 119, 535-536 (codifed 
at 42 U.S.C. § 914). 

[22] As part of this process, the Office of Health Equity, which was 
previously within the Office of Special Health Affairs, began 
reporting directly to the Office of the Administrator. 

[23] Internal control is a component of an organization's management 
that provides reasonable assurance that it is, among other things, 
operating effectively and efficiently. While the standards for 
internal control provide a general framework, it is up to management 
in each agency to implement the standards and to create practices to 
ensure that they are built into and are an integral part of 
operations. See [hyperlink, 
http://www.gao.gov/products/GAO/AMID-00-21.3.1]. 

[24] HRSA also has a process for considering requests for additional 
resources as needs arise outside of the operational planning process. 

[25] Throughout this report, the data on HRSA staffing represents 
staff on board as of September 30, which is the end of the federal 
fiscal year. Our analysis of HRSA staff levels excludes two categories 
of HRSA employees who serve on a temporary basis--1) students, 
interns, and similarly classified individuals, and 2) intermittent 
employees who HRSA officials told us primarily include special 
government employees who generally serve a few days a year on HRSA 
advisory committees. At the end of fiscal year 2012, there were 213 
such employees (41 students, interns, and similarly classified 
individuals and 172 intermittent employees). 

[26] The occupations are defined by occupational series which consist 
of positions that are similar in terms of their specialized line of 
work and qualification requirements. 

[27] The most common occupation for a HRSA project officer is the 
Public Health Program Specialist. 

[28] We define attrition as any departure from HRSA, including 
retirements, resignations, terminations, and deaths. Individuals who 
left HRSA for jobs with other agencies within HHS are counted as 
resignations. 

[29] HRSA's attrition rates for fiscal years 2008 through 2012 were 
9.9 percent (2008), 7.6 percent (2009), 9.3 percent (2010), 8.9 
percent (2011), and 8.8 percent (2012). 

[30] The remaining two percent of departures were due to death. 

[31] In 2012, we reported that around 30 percent of federal employees 
onboard at the end of fiscal year 2011 would become eligible to retire 
by 2016. See GAO, Human Capital Management: Effectively Implementing 
Reforms and Closing Critical Skills Gaps Are Key to Addressing Federal 
Workforce Challenges, [hyperlink, 
http://www.gao.gov/products/GAO-12-1023T] (Washington, D.C.: Sept. 19, 
2012). 

[32] The HRSA retirement eligibility rates we report for GS-15s and 
SES employees are similar to the fiscal year 2011 government-wide 
retirement eligibility rates for the same groups (about 45 percent of 
GS-15s and 58 percent of SES employees). See [hyperlink, 
http://www.gao.gov/products/GAO-12-1023T]. 

[33] See [hyperlink, http://www.gao.gov/products/GAO-02-373SP]. 

[34] The Federal Employee Viewpoint Survey is a tool that measures 
employees' perceptions of whether, and to what extent, conditions 
characterizing successful organizations are present in their agencies. 
Survey results are intended to provide insight into the challenges 
agency leaders face in ensuring the federal government has an 
effective civilian workforce and how well they are responding. The 
Office of Personnel Management administers this survey and provides 
reports to participating agencies that include the results of their 
respondents, including comparisons to results at the agency, 
department, and government-wide levels. One question asks "are you 
considering leaving your organization within the next year, and if so, 
why?" Respondents can indicate: No; Yes, to retire; Yes, to take 
another federal job; Yes, to take another job outside the federal 
government; or, Yes, other. Officials also noted that they use results 
from this survey to gauge employee satisfaction and identify areas for 
improvement to prevent further attrition. 

[35] For example, HRSA officials noted that one bureau has an online 
recognition system that allows employees at all levels to acknowledge 
the accomplishments and contributions of one another by generating a 
recognition email that goes to the recipient, as well as their 
supervisor. 

[36] When an agency awards a contract, it incurs an obligation, which 
is a definite legal commitment that will result in payment at some 
point in the future. The amount of obligations we report accounts for 
any funds that were deobligated within the fiscal year; funds may be 
deobligated, for example, due to a reduction in costs or a correction 
to recorded amounts. In fiscal year 2012, HRSA had just over $2 
million in deobligations. 

[37] A contract may include more than one product or service, but 
agencies can only record one product or service per contract in FPDS-
NG. Our analysis presents the product or service category that HRSA 
recorded for the contract. 

[38] HRSA's Bureau of Health Professions administers the National 
Practitioner Data Bank, which serves as a flagging system intended to 
prompt a comprehensive review of health care practitioners' licensure 
activity, medical malpractice payment history, and record of clinical 
privileges. Used in conjunction with information from other sources, 
the National Practitioner Data Bank assists in promoting quality 
health care, and deterring fraud and abuse in the health care delivery 
system. 

[39] 42 U.S.C. § 274k. 

[End of section] 

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 website [hyperlink, http://www.gao.gov]. Each 
weekday afternoon, GAO posts on its website newly released reports, 
testimony, and correspondence. To have GAO e-mail you a list of newly 
posted products, go to [hyperlink, http://www.gao.gov] and select 
“E-mail Updates.” 

Order by Phone: 

The price of each GAO publication reflects GAO’s actual cost of 
production and distribution and depends on the number of pages in the 
publication and whether the publication is printed in color or black 
and white. Pricing and ordering information is posted on GAO’s 
website, [hyperlink, http://www.gao.gov/ordering.htm]. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 
TDD (202) 512-2537. 

Orders may be paid for using American Express, Discover Card, 
MasterCard, Visa, check, or money order. Call for additional 
information. 

Connect with GAO: 

Connect with GAO on facebook, flickr, twitter, and YouTube.
Subscribe to our RSS Feeds or E mail Updates. Listen to our Podcasts.
Visit GAO on the web at [hyperlink, http://www.gao.gov]. 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 
Website: [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: 

Katherine Siggerud, Managing Director, siggerudk@gao.gov: 
(202) 512-4400: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7125: 
Washington, DC 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, DC 20548. 

[End of document]