|
Office of the Assistant Secretary for Planning and Evaluation |
| |
|
Policy Information Center |
In this chapter, the U.S. Department of Health and Human Services (HHS) highlights evaluations of general interest to the public health, health care services, and human services community, and illustrates the diversity of HHS evaluations completed in fiscal year (FY) 2000. Included are summaries of eight evaluation projects selected by the HHS Evaluation Review Panel, a group of outside evaluation experts. The Panel reviewed a total of 29 reports nominated by HHS agencies and selected these eights reports on the basis of the following criteria:
These criteria are more fully described in the Appendix C.
The eight studies are organized under two headings:program effectiveness evaluations andenvironmental assessments. These headings represent two common uses of HHS evaluation resources.Program effectiveness evaluationprovides a way to determine the impact of the Department’s programs on achieving intended goals and objectives. Environmental assessment is the way we understand the forces of change in the health and human services environment that will influence the success of our programs and the achievement of our goals and objectives.
Reforming Welfare and Rewarding Work: Final Report on the Minnesota FamilyInvestment Program (MFIP).
Summary
Volume I: Impact on Adults
Volume II: Impact on
Children
Highlights:
This final report on an experimental program in Minnesota that combined financial incentives to work with participation or work requirements for long-term welfare recipients provides insight into four major policy issues. The issues addressed were the following:
The evaluation, conducted from April 1994 and March 1996, utilized a random assignment research design to evaluate the MFIP success. More than 14,000 families in seven Minnesota counties were assigned to either the MFIP program or to the traditional AFDC program. The two groups were compared on employment, welfare receipt, and outcome measures related to family life, child well-being and other factors of interest.
Findings indicate single-parent, long-term welfare recipients benefitted most from the MFIP program as evidenced by increases in employment and earnings compared to AFDC participants. However, total costs were higher, since families retained their welfare benefits even as their earnings increased. MFIP families showed improvements in family well-being, as evidenced by parental reports on children’s behavior, a decrease in reported domestic abuse, and a modest increase in marriage rates. For two-parent recipient families, there was an increase in the proportion of parents who stayed married, compared to AFDC, and the program enabled second earners to work less. Results were mixed for recent welfare applicants.
Purpose
This evaluation was designed to assess the costs and benefits of the MFIP project, a program designed to encourage work and reduce dependence on welfare, while simultaneously reducing poverty. Under the rules of the MFIP, recipients of welfare remained eligible for assistance until their income reached 140 percent of the poverty line. Child care costs for working parents were paid directly to child care providers, eliminating the need for a parent to pay for child care up front. In addition, the rules and procedures related to obtaining welfare benefits were simplified.
Background
A new vision of welfare that encourages “making work pay” for low-income families while reducing their dependence on public assistance has emerged over the past decade. This philosophy is embodied in the Personal Responsibility and Work Opportunities Reconciliation Act (PRWORA), which was enacted in 1996. Traditional welfare programs tend to provide disincentives for single mothers to enter the workplace, as benefits are often better than the income that could be obtained. Two-parent families are required to meet stringent eligibility rules that tend to discourage marriage. At the same time poverty rates for families with children in the U.S. have increased since the mid- 1970s. To meet the requirements of the Personal Responsibility and Work Opportunities Reconciliation Act (PRWORA), states have attempted to make work pay by ensuring the transition to work does not result in a decline into poverty
The MFIP program, which was implemented prior to the passage of the PRWORA, demonstrates the results of implementing two complementary policies that previously have been implemented as single approaches: financial incentives that reward work and reduce poverty, and for long-term welfare recipients, mandatory participation in employment-focused services to reduce long-term welfare dependence.
The MFIP program was first implemented as a field trial in April 1994 in three urban and four rural counties in Minnesota. An interim evaluation of the project was provided in 1997. This final evaluation, presented in two volumes and a summary report, covers the period from 1994 through 1998.
Methods
The evaluation design had two components, one directed primarily at the welfare recipients and the other examining the specific effects on children. Between April 1994 and March 1996 over 14,000 families were assigned, using a lottery approach, to the MFIP group or to the traditional AFDC program. A sub-sample of single-mother families with preschool and school-age children who entered the evaluation between April and October 1997 were selected to provide information on impacts of the program on children. MFIP differed from AFDC in three key ways: while in both MFIP and AFDC welfare benefits decreased as earned income rose, the working families in MFIP were allowed to keep more of their monthly financial benefits and to continue to receive these benefits over a longer period of time. Child-care expenses were paid directly to providers, leaving no up-front costs for the parent. MRIP required long-term welfare recipients to participate in employment and training services, while participation in training programs was voluntary under the AFDC program. The MFIP program combined AFDC, Minnesota’s Family General Assistance and Food Stamps into a single monthly payment. In addition, the program rules were simplified, particularly for two-parent families.
There were two sub-groups of MFIP recipients in both the single and two-parent families; those considered long-term welfare recipients (mothers on welfare at least 24 of 36 months prior to random assignment) and recent applicants. Recent applicants were not required to participate in the mandatory employment aspects of the program.
The effects of MFIP were evaluated by comparing outcomes for families randomly assigned to MFIP with outcomes for families randomly assigned to the AFDC system. For the subsample, data on family and child well-being were collected from a survey administered to the families three years after they entered the program. The survey collected information on child and family well-being, including family employment and income; parents’ psychological well-being and parenting practices; and children’s health, behavior and school progress. Data were also collected from administrative case records.
Findings
Throughout the 3 year period following their assignment, single-parent long-term recipients (SPLTR) on MFIP had increased employment rates and increased average earnings. These effects were smaller in the rural counties. MFIP increased the number of SPLTR on welfare, but reduced the number relying solely on welfare. MFIP increased incomes and reduced measured poverty. SPLTR MFIP recipients were more likely to be married than AFDC recipients at the end of the 3 year period.
Single parent, recent applicants (SPRA) on MFIP demonstrated modestly increased employment but not increased earnings during the same 3 year period. MFIP actually increased the number of SPRA on welfare, but reduced the number relying solely on welfare. Two-parent long-term recipients (TPLTR ) were less likely than AFDC families to have both parents working, leading to lower family earnings. While MFIP increased the proportion of TPLTR receiving welfare benefits, program participants also showed increased marital stability, income, and home ownership. MFIP had little effect on employment, earnings, or income for two-parent recent applicants (TPRA) families.
For both SPLTR and SPRA the MFIP financial incentives increased employment and earnings, but they also caused some working parents to reduce their hours. Increases in income resulting from financial incentives were responsible for antipoverty effects. The program cost more per family per year than did the AFDC system, because of this increased support for working families.
Compared to financial incentives alone, the complete MFIP program increased full-time work and earnings. SPLTR in the sub-sample also reported improvements in child-well being and declines in domestic abuse. Their children exhibited fewer behavioral problems and did better in school than children of mothers on AFDC. Children were also more likely to be placed in child care, particularly in child care centers, and were more likely to have continuous health coverage. The mothers were more likely to work and had higher incomes. Mothers of these children were also more likely to marry and less likely to experience domestic abuse than recent applicants.
Findings for children of more recent applicants (for whom job preparation services were not mandatory) reported had similar levels of behavioral problems and school progress for their children compared to children of AFDC mothers. Their children were more likely to have had continuous health coverage. The mothers were only slightly more likely to work, did not have higher incomes, and experienced few other changes in their well-being compared to AFDC participants.
In summary, MFIP has been most efficient for SPLTR, the group that is the largest and that was the major target for the program.
Use of Results
The evaluation addresses three goals that have emerged as high priorities under PRWORA: ensuring that long-term welfare recipients make substantial strides toward self-sufficiency before realizing their time limit on welfare receipt, supporting the efforts of low-income workers to advances in their jobs while providing adequately for their families, and assuring that social policies do not discourage marriage. Lessons learned from this evaluation provide important information on types of families for which this approach is most effective; which components of the program; financial incentives, mandatory employment and training B contribute to the effects; and the non-economic effects on both families and children;
AGENCY SPONSOR: Office of Planning, Research and Evaluation and the Office of Child Support Enforcement at the Administration for Children and Families (ACF)
FEDERAL CONTACT: Lawrence Wolf
PHONE NUMBER: 202-401-5084
PIC ID: 6824
PERFORMER ORGANIZATION: Manpower Demonstration Research
Corporation,
New York, NY
* * * * * *
The Outcome of Outcomes Research at AHCPR: Final Report
Highlights
This report was prepared for use in discussions of strategic directions for the Outcomes and Effectiveness Research (OER) program at AHCPR, now the Agency for Healthcare Research and Quality (AHRQ). It covers three topics: 1) a conceptual framework for understanding and communicating the impact of OER on health practice and outcomes, 2) a critical analysis of accomplishments and lessons learned over the past decade, and 3) a list of recommendations intended to maintain AHCPR strengths while increasing the measurable impact of future research. It examines issues of how the OER program at AHCPR can most effectively advance the field of health services research (HSR), fulfill its unique role in HSR, contribute to public health, and address the expectations of policymakers and stakeholders. Research findings in OER were classified according to four levels of impact: 1) findings that contribute to an area’s knowledge base and help focus subsequent research (e.g., new analytic methods), 2) research that prompts creation of a new policy or program (e.g., incorporating medical guidelines into practice), 3) a change in what clinicians and patients do, and 4) actual changes in health outcomes.
Conclusions and future directions identified based on these findings suggest that OER must move beyond hypothesis testing and unchannelled intellectual explorations to address knowledge gaps and address areas of application. It suggests that OER should leverage resources through partnerships with HCFA and other public and private organizations, moving from a tool using-culture to a problem-solving culture. Also, OER should develop and refine the “conceptual infrastructure” for conducting effectiveness trials, building on the effectiveness initiatives and PORTS of the 1980s. The study also identifies a need for AHCPR to develop a “dedicated knowledge transfer function” to help engage policymakers and other stakeholders in understanding the links between basic research and clinical practice.
Purpose
This report is intended both for use within the Agency for Health Care Policy and Research (AHCPR) to guide internal discussions, and for external researchers involved in outcomes and effectiveness research (OER). The key question addressed by the report is how the OER program at AHCPR can most effectively advance the field of health services research, contribute to public health, and address the expectations of policymakers and stakeholders. Through a review of accomplishments within the agency, the report provides lessons learned and recommendations for improvement.
Background
Since program inception in 1989, the AHCPR has had the primary responsibility for implementing theEffectiveness Initiative. The theoretical model underlying effectiveness research in health care is that the retrospective study of patterns of care leads to the definition of optimal treatments; this in turn could lead to substantial economic savings in the subsequent delivery of health care. AHCPR was established as an embodiment of this hypothesis that guidance for optimal medical practice can be obtained from analysis of data that is routinely gathered in the process of delivering and paying for patient care. The intent of this report is to review the evidence that this is a valid approach.
Methods
The study is based on a review of articles from grants, original concept papers for launching the “outcomes movement” and critiques of the same, analysis of private sector involvement in OER, a survey of Principal Investigators (PIs) and interviews with selected PIs, interviews with a former the Director of the Center for Outcomes and Effectiveness Research (COER), discussions with the COER staff, and recommendations made by investigators and stakeholders at two expert panel meetings. The PI survey was based on the premise that researchers should have a clear understanding of the impact of their own research. It achieved a 64% responserate, including 61 of 95 PIs.
The impact of AHCPR OER research was categorized into four levels: (1) findings that contribute to a change in practice or policy by adding knowledge or helping to focus subsequent research; (2) research findings that are incorporated into the creation of a new policy or program; (3) an actual change in what clinicians or patients do; and (4) a change in a health outcome. The first item is essentially descriptive research focused on descriptions of what occurs in the health area and in developing tools for measuring costs of care and patient reported outcomes, and identifying topics for future research.
Findings
Results suggest that PIs have been most successful in providing descriptions of what actually occurs in health care, developing tools for measuring costs and outcomes, and identifying topics for future research. Other study findings include evidence that OER has increased recognition in the medical community that evidence, not opinion, should guide clinical decision-making; acceptance that a broader range of patient outcomes needs to be measured to understand the benefits of interventions; and the perspective that research priorities should be guided in part by public health needs. The study also found that the most concrete accomplishments in 10-15 years of OER are the tools and methods developed.
Use of Evaluation Results
Although it is increasingly evident that observational designs, such as those that predominate at OER, cannot provide definitive answers regarding clinical effectiveness, these studies do produce information about benefits, risks and costs of health care. Change is dependent upon use of the information by decision makers. Suggested options to enhance the positive impact of the research include:
AGENCY SPONSOR: The Center for Outcomes Effectiveness Research at the Agency for Healthcare Research and Quality (AHRQ),
FEDERAL CONTACT: Carolyn M. Clancy
PHONE NUMBER: 301-594-1485
PIC ID: 5979
PERFORMER ORGANIZATION: The Lewin Group, Fairfax VA
* * * * * *
Infant Immunization with Acellular Pertussis Vaccines in the United States: Assessment of the first Two Years’ Data From the Vaccine Adverse Event Reporting System (VAERS)
Highlights
The safety of the new acellular pertussis vaccines was evaluated utilizing the Vaccine Adverse Event Reporting System (VAERS) a passive national surveillance system. Reports of adverse events reported to VAERS in conjunction with an immunization against pertussis (whooping cough) between January 1, 1995 (when the whole-cell vaccine was used exclusively) and June 30, 1998 (when the acellular vaccine predominated) were analyzed. Differences in reported events, categorized according to level of seriousness (fatal, non-fatal serious, less serious), were evaluated for three types of vaccines: Diptheria-tentanus-pertussis (DTP) diptheria-tetanus-whole-cell pertussis-Haemophilus influenzae type b (DPTH) and diptheria-tetanus-acellular (DtaP). The results showed a decline in total adverse events reported in the less serious and non-fatal serious report categories. There was not a concomitant decrease in fatal events; in general these events are rare. The authors conclude that the decrease in the number of less serious reports after vaccination with pertussis-containing vaccines while utilization of the DtaP form of the vaccine was increasing, is consistent with information obtained from clinical trials of the acellular vaccine. In addition, an analysis of the proportional distribution of specific events within each category did not show a substantial increase in any event. No new safety concerns surrounding the administration of acellular pertussis vaccine were identified. .
Purpose
The purpose of this study was to evaluate the safety of infant immunization with acellular pertussis vaccines in the United States utilizing the VAERS data. This particular type of vaccine has been licensed for infants recently and is intended to replace the whole-cell vaccines. Although pre- licensure studies were conducted, post-licensure surveillance on a larger scale is required to ensure safety.
Background
The development of an acellular pertussis vaccine resulted from concerns about the safety of whole- cell pertussis vaccines that arose during the 1970s and 1980s. The acellular pertussis vaccine was initially developed and licensed for older children in 1991, and was more recently (1996) instituted for infants. Although clinical trials conducted during the pre-licensing phase of drug development provide initial information on safety, sample sizes are necessarily limited. This in turn limits the ability to detect the occurrence of very rare adverse events during prelicensure trials. Post licensure surveillance systems, such as the VAERS, provide the opportunity to review data for millions of doses.
The VAERS was established in 1990 to provide information on adverse events associated with vaccinations. Reporting to VAERS is mandated by the National Childhood Vaccine Injury Act for specific adverse events occurring within specified time intervals after listed vaccines. The VAERS reporting form contains information on demographics, vaccinations(s) administered, description of the adverse event, treatment, and severity. Reporting may be done by physicians, nurses, pharmacists, parents, vaccines, and others. The reports to VAERS do not necessarily represent causal relations between vaccinations and adverse events, although they are temporally related events.
Although passive surveillance systems such as the VAERS have their limitations, they do provide the ability to: detect previously unrecognized adverse events, provide additional clinical insight into recognized adverse events, and assess the safety of newly licensed vaccines
Methods
The VAERS data encompassing domestic reports from January 1 1995 through June 1998 were obtained for infants (less than 1 year of age at time of vaccination). Time trends in number of VAERS reports according to severity of adverse event and type of pertussis vaccine were presented. The coding of severity for adverse events was based on definitions from the Code of Federal Regulations: reports of death, non fatal serious events (initial hospitalization, prolongation of hospitalization, life-threatening illness, or permanent disability), and reports of less serious events. In addition, selected reports of adverse events associated with DTP vaccinations were individually reviewed to verify that the reported diagnoses were correctly coded.
Findings
Trend analyses showed a sharp decline in the total number of reported serious and less serious adverse events associated with pertussis vaccine administration during the transition from use of whole-cell pertussis vaccine to predominant use of acellular pertussis vaccine. A similar clear-cut decline was not observed for reports of deaths. An analysis of the proportional distributions of adverse events within the three types of vaccines indicated no specific event was occurring at a substantially higher proportional rate for the acellular vaccine versus the other vaccines. Urticaria (hives) was noted in 7.7% of the DTP vaccine, compared to about 3% for both DTP and DHTP vaccines, but this was not associated with anaphylaxis, and may have been due to the proportional decrease in reports of fever, which are proportionally higher for both the DTP and DHTP vaccines.
Use of Evaluation Results
The safety of the acellular vaccine demonstrated by the pre-licensure clinical trials is confirmed by the current surveillance study.
AGENCY SPONSOR: Center for Biologics Evaluation and Research at the Food and Drug Administration (FDA)
FEDERAL CONTACT: Miles M. Braun, MD, MPH
PHONE NUMBER: 301-827-3974
PIC ID: 7251
PERFORMER ORGANIZATION: Center for Biologics Evaluation and Research at the Food and Drug Administration (FDA), Rockville, MD and the National Immunization Program at the Centers for Disease Control and Prevention (CDC), Atlanta, GA
* * * * * *
National Health Service Corps
Highlights
The National Health Service Corps (NHSC) is a program intended to improve access to health care in underserved areas. The program is conducted under the auspices of the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA). This evaluation of the NHSC examined the factors that are hypothesized to lead to clinician retention in underserved communities. The study consisted of in-depth surveys of three groups: NHSC alumni clinicians, current clinicians, and NHSC site administrators.
The NHSC program provides either scholarships to currently enrolled students or a loan repayment program for those who recently completed their training. Providers in both programs are then obligated to practice in a high-priority health professional shortage area, or in the case of the loan repayment program, eligible facilities from the Loan Repayment Vacancy List. The agency asserts that many of their providers, in addition to caring for patients, contribute in other ways to medical care at their host sites. This assertion has not been previously studied and became a major focus of this evaluation.
Questionnaires were sent to a stratified sample of 2,160 alumni physicians, advanced practice nurses, dentists, and physicians assistants, who have participated in the program over the past twenty years, as well as to 1,143 currently serving providers. Seventy five percent of current providers and 59% of alumni responded to the survey. (Sixty-two percent of NHSC site administrators also responded to a mailed survey.) Descriptive statistics, univariate, and multi- variate analyses of the data were presented. The predictors included program characteristics, individual provider background characteristics, and self-reported attitudes. Findings were many and complex, given the multiple outcome measures, but generally supported the conclusion that participants in the loan repayment program exhibited better outcomes than did providers in the scholarship program. Other programmatic, attitudinal and background characteristics such as gender, discipline, type of site, site match with provider choice and motivation for entering the program were also associated with various outcomes. Survival analysis using Cox regression models were employed to investigate retention over time.
Main findings were that satisfaction with the program varied according to numerous demographic factors as well as with the type of program (scholarship vs loan repayment) the provider was enrolled in. Providers, primarily physicians, in rural communities have had an impact on their communities in areas other than direct patient care.
Purpose
The purpose of the current evaluation was review the NHSC program in 3 areas: assess the extent to which the NHSC is fulfilling its mission, improving clinical practice standards in underserved areas, and contributing to the community in other areas; identify factors that influence the quality of service and retention; and assess the impacts of changes in program objectives and expectations on development of the NHSC.
Background
The NHSC was established in 1971 and is part of a larger Federal effort designed to improve the delivery of health services to persons in currently underserved areas. Primary health care professionals, including physicians, dentist, nurse practitioners, physician assistants, certified nurse midwives, and others, are recruited and placed in underserved areas through two methods: 1) scholarship programs, which require assignment to a specific area for the length of service equal to the scholarship term; and 2) loan repayment, which requires assignment to a wider variety of sites while NHSC assists with repayment of loans incurred during clinical training. Although the mission of the program has changed only slightly, the approach and levels of funding available to the program have varied greatly over the 25 years since inception. As of August 1999, when the study was conducted, there were approximately 1,863 NHSC clinicians in the field; 70% were federal loan repayment participants and 30% were scholarship recipients. More than half of the clinicians in the field at that time period were physicians (51%), 14% were dentists, 14% were physician assistants, 11% were nurse practitioners, and 3% were nurse midwifes. The remaining 7% were in disciplines considered to be out of the scope of the current evaluation (mental health workers, marriage therapists, etc.). Previous evaluations have focused primarily on physicians, rural areas, and scholarship programs. The current effort broadens the scope of the program evaluation.
Methods
Information was obtained via mail surveys of NHSC current and former clinicians, and NHSC sites administrator. The surveys were self-administered and contained both structured and open-ended questions. The objectives of the surveys were to assess clinician impact on the sites and communities, and to assess factors that influence both retention at the site and subsequent career objectives of the NHSC clinician. The clinician surveys evaluated experience before NHSC service; NHSC service; service impacts; satisfaction with practice setting; education and employment history; and socio-demographic characteristics. The site administration survey covered the site historical involvement with the NHSC program; site clinical services; compensation approach; and NHSC recruitment and retention record.
Findings
Response rates for survey returns were 75.2% for current clinicians, 58.9 for alumni clinician, and 62.1% for site administrators. Important motivations for joining the corps were financial need and a desire to work with underserved populations based on altruistic motivation (as measured by a composite of three questions). Overall satisfaction levels among alumni and current clinicians are not high, and were found to vary by such factors as discipline, type of community, gender, age at start of service, and ethnicity. Selected findings are: Scholarship program participants are less satisfied than loan repayment clinicians, possibly due to less choice in sites for work effort. Non- physician primary care workers are more satisfied with both compensation and job situation than are physicians. Rurally located clinicians are less satisfied than those at other sites; female clinicians and their families report lower satisfaction compared to males, as do younger participants.
The study also revealed that NHSC clinicians have had an impact on their communities in areas other than direct patient care. These include accessing new patient populations; increasing and adding services, initiating community-oriented primary care programs, participating in quality assurance activities, and engaging in leadership activities. This is more true for those clinicians in rural communities than those in urban areas.
Use of Evaluation Results
Results can be utilized to assist the NHSC program select applicants who are well suited to carry out the mission of the corps. The selection and recruitment process can be improved by matching NHSC clinicians to communities that provide a good fit, leading to higher performance and increased retention.
AGENCY SPONSOR: Bureau of Primary Health Care at the Health Resources and Services Administration (HRSA)
FEDERAL CONTACT: Richard Niska, MD
PHONE NUMBER: 301-594-4204
PIC ID: 6357
PERFORMER ORGANIZATION: Mathematica Policy Research, Inc., Washington, DC
The Low Wage Labor Market: Challenges and Opportunities for Economic Self-Sufficiency
Highlights
This study represents a synthesis of current literature on the low-wage labor market. The purpose of the study is to identify labor market factors that influence the prospects of former welfare recipients finding work leading to economic self-sufficiency. The study consisted individual papers on specific labor market topics prepared by nine experts in the low wage labor market field. The study topics included (1) description of the low-wage labor market and how has it changed over time, (2) policies affecting the low wage labor market, (3) identification of barriers to entering the low-wage labor market, and (4) barriers to advancement in the low wage labor market. The nine experts highlighted several policy options for improving the wage, employment, and economic self-sufficiency outcomes of low-wage workers.
The research methodologies included a comprehensive literature review of labor market studies, evaluations of job training programs and other labor market related policies, and review of existing labor market data covering the 1960's to the present. The study also includes a compilation of labor market data from the Current Population Survey, the Bureau of Labor Statistics, and the Survey of Income and Program Participation.
The study concluded that the nation’s labor market will be able to absorb the welfare recipients leaving welfare for work as long as the economy remains strong, but there will be regional disparities in the rate of absorption. There will be fewer low-wage opportunities in urban areas and in the South and West regions of the country. In terms of economic self-sufficiency, the study makes it clear that former welfare recipients will continue to be concentrated in jobs that are low-wage, have few fringe benefits, little opportunity for advancement, and are subject to high turnover. The policy recommendations to improve the wage, employment, and economic self-sufficiency of low-wage workers include: (1) policies to improve labor market access and job retention, (2) policies to encourage or support occupational mobility/job advancement, (3) policies to raise the incomes of low wage workers and enhance employment security.
Purpose
There is an increased emphasis on moving welfare recipients into employment. The labor market faced by these individuals differs from the general model of a labor market in that the jobs do not have opportunities for advancement, little job security, and the individuals are subject to gender and racial discrimination to a greater degree. Due to the substantial size of this workforce, a characterization of the workforce and the polices that affect it was undertaken.
Background
Policy makers are concerned about the impact of moving welfare recipients into employment as a result of welfare reform. The impact of these changes on the labor market’s ability to absorb these new workers, the opportunities that are available, and the effects of changes in the larger economy are largely unknown. The U.S. Department of Health and Human Services, Office of the Assistance Secretary for Planning and Evaluation, commissioned nine papers by expert in labor market analysis, requesting they review the current literature on the low-wage labor market and highlight policy implications. This document represents a compilation and summary of those reviews. The papers characterized the low-wage labor market, how it varies over time, and how outcomes vary for different populations and regions. Three other papers addressed the impact of specific policy interventions intended to increase income or employment among the working poor. Two papers addressed the barriers to employment experienced by disadvantaged workers. The last two papers reviewed opportunities for advancement and job-related benefits in the low wage labor market.
Methods
This document represents a collection of papers by experts, who reviewed the literature relevant to their area of expertise. The literature was reviewed with the purpose of providing assessments of policies.
Findings
Each reviewer provided a number of findings and recommendations. A summary of key findings includes the following: The wage level of low income workers has declined over time. These low- wage workers are disproportionately female, minority, non-college-educated, non-union and concentrated in retail trade. Although the skill level of low-wage workers has steadily increased over time, there has not been a concomitant increase in wage share. Individuals with high school or less have higher unemployment rates, and earn less. The number of low-wage jobs is cyclical. Labor prospects for former welfare workers are less than those for other groups of workers. There is a falling demand for low-skilled labor. There are regional differences in the characterization of the job market. There has been real growth in the employment rate of single mothers, but in many cases there has been no real difference in net income. The labor market will be able to absorb the influx of individuals leaving the welfare rolls only of the economy remains strong. Specific areas of the country may experience difficulty if the economic conditions change. Jobs for welfare recipients are limited, given the skill levels and educational background of most welfare recipients. Public job creation does appear to generate new jobs for low-skill workers, if the earned Income Tax Credit does increase employment for single-parent families. Barriers to employment for low-wage workers include racial discrimination, lack of information about and access to suburban jobs, and lack of effective networks and contacts. Informal referrals may produce a segregated workforce that actually acts as a barrier to those not within the network. Training programs and work programs have only small effects. Less-educated workers are disproportionately affected by turnover.
Use of Evaluation Results
Several policies are highlighted that the authors feel will improve the wage employment and economic self-sufficiency outcomes of low-wage workers. These include:
AGENCY SPONSOR: Office of the Assistant Secretary for Planning and Evaluation in the Office of the Secretary (OS)
FEDERAL CONTACT: Kelleen Kaye
PHONE NUMBER: 202-401-6634
PIC ID: 7425
PERFORMER ORGANIZATION: Urban Institute, Washington DC
* * * * * *
A National Study of Assisted Living for the Frail Elderly
Highlights
This report represents the first in a series of planned reports based on data collected from surveys of a national probability sample of assisted living facilities (ALFs). The philosophy of assisted living is desirable to a variety of stakeholders, and the growth of such facilities has been extensive. Due to the variability in both the definition and regulation of such facilities across states, there are concerns about both the quality of care and consumer protection issues. This report is intended to provide a descriptive overview of a stratified random sample of such facilities, including services provided, costs, and consumer satisfaction. The overall study will review trends in demand for and supply of ALFs; identify barriers to the development of ALFs and determine the extent to which the current supply of facilities meets the concept of “Assisted living”; define what the ALF concept embodies; and look at key features that affect consumer satisfaction, autonomy, affordability, and potential to receive nursing home level of care. The current study is the first step in the process, and provides a descriptive look at basic characteristics of the industry, particularly in terms of services, accommodations, and price.
The study found there are approximately 11,432 ALFs nationwide, with about 650,000 beds. The average occupancy rate is 84%. Most ALFs offered some degree of privacy, with approximately 50% of the units comprised of a one-bedroom, single occupancy apartment. The study also determined that places called ALFs differed greatly with respect to a variety of factors. The extent to which the environment and services of the facilities match the philosophy of assisted living is mixed. Although residents can age in place to some degree, those requiring extensive help with transfers or whose cognitive impairment was moderate to severe could not remain at these facilities. In general, it was determined assisted living was not affordable for moderate and low-income persons aged 75 or older.
Purpose
The purpose of the study is to describe the role assisted living facilities play in providing a residential setting and supportive long-term care services to the elderly. This initial report is primarily descriptive in nature, providing information on the size and nature of the supply of assisted living facilities, the basic characteristics of the industry, and what philosophy is embodied by the current supply of facilities.
Background
There is an increased demand for residential facilities that offer supportive services for the frail elderly due to a rapidly growing elderly population with significant levels of physical disability and mental impairment, a preference of the elderly for in-home and community-based services, and incentives at the state level to constrain theuse of nursing homes. ALFs are defined differently across states, and are regulated by a wide variety of different state agencies.
Methods
The survey utilized a complex, multi-stage sampling design to identify and select assisted living facilities (ALFs). Of the estimated 11,472 potential ALFS identified via external sources (e.g., state licensure agencies, industry trade associations, Internet listings), a stratified random sample of 2,945 places was selected for telephone survey screening. Of these, facility administrators at 1,251 that met eligibility criteria were given an extended telephone survey. The study considered an ALF to meet criteria if it had more than ten beds; served a primarily elderly population, and offered a basic level of services, including 24-hour staff oversight, housekeeping services, at least two meals a day, and some degree of personal assistance.
Findings
The study found there are approximately 11,432 ALFs nationwide, with approximately 650,000 beds. The average occupancy rate is 84%.The average size of an ALF in the survey was 57 beds; 67% had 11-50 beds, 21 percent had 51-100 and 12% had more than 100 beds.
Most ALFs offered some degree of privacy, with approximately 50% of the units comprised of a one-bedroom, single occupancy apartment. Few of the facilities had all-private accommodation; with approximately 28% reporting bedrooms could be shared by three or more residents.
Most of the facilities offered 24-hour staff, three meals a day, and housekeeping. Most (three- quarters) also had some type of nursing staff available either full or part-time Although individuals with moderate disabilities were admitted, fewer than half of the facilities would admit residents who required help with transfers. Those residents with moderate to severe cognitive impairment were also barred from more than half of the ALFs.
The study authors categorized the facilities based on a mix of services and the amount of privacy afforded. The four groups were low/minimal privacy and low/minimal services, representing 59% of the total; high privacy but low services (18%); low privacy, high service (12%) and high privacy and high service (11%). These groups differed significantly from each other, although all called themselves assisted living facilities.
The most common basic price for the facilities ranged from $1000 to $1999 per month, with the high privacy/high service facilities at the top of the range. These rates are largely unaffordable for low- and moderate-income elderly.
Use of Evaluation Results
This report, the first in a planned series, provides a descriptive overview of ALFs, including services provided, costs, and consumer satisfaction. The findings from this report can be used in future discussions to delineate and define the concept and philosophical models of assisted living facilities. The study provides a look at the extent to which the current supply of facilities meets the concept of “assisted living,” and provides definitions of what the concept embodies. Future reports will examine trends in demand for and supply of ALFs; identify barriers to the development of ALFs; and will provide a look at key features that affect consumer satisfaction, autonomy, affordability, and potential to receive nursing home level of care.
AGENCY SPONSOR: Office of Disability. Aging and Long-Term Care Policy at Office of the Assistant Secretary for Planning and Evaluation (ASPE)
FEDERAL CONTACT: Pamela Doty
PHONE NUMBER: 202-690-6613
PIC ID: 4719.7
PERFORMER ORGANIZATION: Meyers Research Institute at Menorah
Park,
Beechwood, OH
* * * * * *
Evaluation of the Research Centers in Minority Institutions
Highlights
The Research Centers in Minority Institutions (RCMI) is a congressionally mandated program designed to expand health sciences research in predominately minority institutions. The primary goal of the program has been to enable these institutions to become more competitive in obtaining support for the conduct of biomedical and or behavioral mission of the U.S. Public Health Service. This program, initiated by the National Institutes of Health (NIH), has been underway since 1985; in 1995, NCRR began a two-phase evaluation of the program to assess the extent to which the goals and objectives of the program are being met.
The current evaluation design addressed six questions:
Information was obtained from interviewing the centers and conducting a site visit, from a review of program record documents; and database searches of secondary data sources
In general the 15 RCMI institutions showed a greater improvement in competing for research grants, with somewhat more experienced centers demonstrating a greater percentage increase in research project grant (RPG) funding per year than either inexperienced or highly experienced centers. The recommendations from the review include a set of data elements that need to be collected to enhance the quality of future evaluations of the program.
Purpose
Phase I of this evaluation, begun in 1995, was intended to look at the first 10 years of RCMI program implementation. This report represents the results of Phase II of the RCMI Program evaluation, which incorporates the plan and methodology developed in Phase I.
The purpose was to provide a scientifically sound evaluation of the 15 RMCI centers that have been funded for at least 10 years to enhance understanding of the program success and program characteristics and activities; to identity best practices implemented at different centers; and develop an improved process for selecting and monitoring the progress of the RCMI centers.
Background
The RCMI program is intended to enhance the research capabilities of institutions with predominately minority student enrollments that offer doctoral degrees in the health professions or in a health-related science. The institutions have historically not participated extensively in NIH research programs. RCMI grants have been awarded to 21 institutions to date, although only 15 have been funded for more than 10 years. The grants provide support for administrative activities, individual faculty member support, and facility enhancement and improvement. Grant recipients all have interest in minority health issues, but differ markedly in their characteristics. Institutions supported include medical schools, graduate school, schools of pharmacy and a school of veterinary medicine. The institutions are both private and state-supported, and range from completely inexperienced in the research area to those with long-standing research programs. The program was initiated in 1985, and therefore has been underway for over 10 years. It was determined a broad-based evaluation was needed to assess the extent to which the goals and objectives of the program were being reached.
Methods
The evaluation was designed as a multiple case study with cross-site analysis, addressing six areas of program characteristics and activities that were hypothesized to have an effect on RCMI success. These characteristics included years of prior research experience and characteristics of the academic research environment. The data included field observations of the RCMI (preceded by a request for specific information prior to the site visit); a review of program records; and data searches of NIH and NSF grant files, bibliometric databases, and other secondary data sources. Comparisons were made between the RCMI and non-RCMI. The comparison non-RCMI group was matched by census region, Carnegie classification, and level of NIH funding prior to 1985. The RCMI were also divided into three groups for within group comparisons based upon level of research funding prior to 1985. The three group identifications were, (1) experienced centers, (2) somewhat experienced centers, and (3) experienced center. The within group comparisons included differences in success in achieving the program outcomes, and differences in organizational and research environmental factors that influenced the outcomes. Both qualitative and quantitative data analysis were conducted to describe the activities of the RCMI, the environmental settings, and research capacity building outcomes. The primary analytical technique was pattern coding, which involved analyzing the items and possible explanations and the patterns to provide factors critical to programmatic success. The preliminary findings were presented to a panel of experts selected by area of research expertise to review the findings and make recommendations to NCRR.
Findings
A summary of the findings of the study are (1) the RCMI showed greater improvement in the completion of grants than the non-RCMI comparison institutions, (2) somewhat experienced institutions showed the best performance in securing competitive grants, (3) the RCMI increased productivity in publications, (4) RCMI increased the number and quality of shared research facilities, upgrading their facilities and equipment, and (5) factors that contributed to some RCMI being more successful than others included scientific leadership, administrative leadership, good management and communication systems, and particularly in less experience institutions, effective strategic planning and self-assessment.
Use of Evaluation Results
The recommendations from the expert panel are (1) NCRR should define and emphasize the long-term goals of the RCMI Program, (2) the NCRR should make it very clear to the administrators of the RCMI that future performance will be measured by demonstrated improvement in competitive research grants, peer-reviewed scientific publications, and successful institutionalization of research capacity to eliminate dependency on RCMI support.
AGENCY SPONSOR: National Center for Research Resources at the National Institutes of Health (NIH)
FEDERAL CONTACT: Patricia A. Vorndran
PHONE NUMBER: 301-435-0866
PIC ID: 5580.1
PERFORMER ORGANIZATION: Macro International Inc., Calverton, MD
* * * * * *
Prescription Drug Coverage, Spending, Utilization, and Prices
Highlights
Although the use of prescription drugs are increasingly improving health outcomes and quality of life, these drugs, and in particular new drugs, are not available to everyone. The elderly and disabled Medicare beneficiaries in particular have either inadequate or no coverage for drugs. Policymakers are currently considering options to make prescription drugs available to all, particularly by expanding the Medicare program; accurate and comprehensive information on drug coverage, drug spending, and drug prices is needed to guide that discussion. The intent of this report is to provide information on drug costs and trends for Medicare beneficiaries. Using a combination of public and private databases, data on coverage, effects of coverage on spending and utilization, and prescription drug prices is provided.
Purpose
The purpose of this study was to examine prescription drug costs and trends for Medicare beneficiaries. This information will be used by policymakers for development of a voluntary Medicare drug benefit as a means to extend drug coverage for senior citizens.
Background
Prescription drugs improve health outcomes, reduce the need for surgery, and can improve the quality of life. New drugs are continually coming on the market with the promise of greater benefits. However, not everyone has access to these drugs. Medicare has never covered the vast majority of prescription outpatient drugs, a common practice for health coverage plans when Medicare was enacted. Most private insurance plans today do provide coverage, and policymakers are aware that this gap in Medicare places a heavy financial burden on beneficiaries. There is a broad plan to modernize Medicare, part of which would involve giving all beneficiaries access to affordable, high-quality drugs
Methods
The data in the report were compiled by the Agency for Healthcare Research and Quality (AHRQ, the Food and Drug Administration (FDA), the Health Care Financing Administration (HCFA) and the Office of the Assistant Secretary for Planning and Evaluation (ASPE). Data were drawn primarily from the 1996 Medical Expenditure Panel Survey (MEPS) and the Medicare Current Beneficiary Survey (MCBS). Additional data were drawn from pharmacy audits conducted by IMS Health, the ongoing Consumer Expenditure Survey (CES) conducted by the Bureau of Labor Statistics and the 1997 National Health Interview Survey. Data on operations of the drug distribution system, industry trends and other information on drug coverage, utilization, spending and pricing were drawn from informal surveys of outside sources such as drug manufacturers and pharmacies.
Findings
Although 85% of Medicare beneficiaries use at least one prescription drug annually, only 54% were covered for a full year during 1996, and 25% had no coverage. Most sources of drug coverage for these individuals are unstable; and drug benefits are becoming less generous. It is expected that drug coverage for retirees will continue to decline. The very old, those who live outside a metropolitan area, and those at the higher end of the poverty spectrum are the least likely to be covered. Currently, rates for prescriptions are higher for those with five or more chronic conditions. There are very significant differences in drug utilization and out-of-pocket spending between those with coverage and those without, regardless of health status. Prescription drugs represent a significant source of spending, taking up about one-sixth of all health spending by the elderly. Cash customers pay more for drugs than do those with third party payments.
Use of Evaluation Results
The study provides a detailed examination of multiple factors related to coverage, utilization, and spending for prescription drugs, particularly for the Medicare population. While providing the requested background, it also raised a number of questions that will require multivariate analyses and an ongoing analysis of more up-to date data to fully answer.
AGENCY SPONSOR: Office of Health Policy at the Office of the Assistant Secretary for Planning and Evaluation (ASPE)
FEDERAL CONTACT: Christy Schmidt
PHONE NUMBER: 202-690-6870
PIC ID: 7506
PERFORMER ORGANIZATION: Office of the Assistant Secretary for Planning and Evaluation at HHS, Washington, DC