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Policy Information Center Highlights: Vol. 3, No. 2

In This Issue:




Studies indicate that a large number of today's young people run a moderate to high risk of failing in school, engaging in early sexual activity, using alcohol and other drugs, and exhibiting criminal behavior. Historically, most youth programs have had a single-problem focus. There are, however, a few innovative programs that attempt to deal with the whole child and see the youth in the context of the family and the neighborhood.

The report, Comprehensive Service Integration Programs for At Risk Youth, assesses how integrated, comprehensive services are provided for at-risk youth between the ages of 10 and 15 and identifies effective methods of delivering these services. In addition, the study examines factors that impede or facilitate these services; describes the roles of the federal, state, and local governments in achieving service integration (SI) for at-risk youth; explains key issues in planning and implementing SI programs; and discusses relevant issues that merit further research.

Literature reviews indicate that the ideal SI program would provide comprehensive, individualized assessments at or near the point of intake; coordinated service plans to ensure that all needs are met; institutionalized agency linkages to gauge whether referrals result in service delivery; and follow-up on referrals to determine whether services are delivered appropriately. Site visits to nine programs in six locations reveal that few existing systems meet all the elements of the SI model. These projects do, however, deliver a wide range of prevention and treatment services to at-risk youth, they strive to provide comprehensive services, and most employ SI to deliver a broad range of services.

The programs reviewed for this report use both formal and informal methods to enhance access to services and to deliver services to clients, and they use different types of volunteers to expand their service options. All of the projects encounter a number of obstacles to SI, including problems in using categorical funding, dealing with the administrative procedures of different agencies, and competing against other agencies for funding.

Those programs that successfully provide SI find that clients receive a greater number of more appropriate services, that participating agencies tend to follow through on tasks more quickly and thoroughly, and that the community-building philosophies of SI projects are attractive to employees, increasing their commitments to programs and stabilizing staffing patterns. Most projects are interested in conducting program evaluations, but vary in their abilities to do so.

The study was conducted by the Urban Institute under contract to the Office of the Assistant Secretary for Planning and Evaluation. The study's project officer, Emily Novick, can be reached on 202-690-5880. Copies of the executive summary, #4646, are available from PIC.




Since the early 1980s, the Health Care Financing Administration (HCFA) has expanded the role of health maintenance organizations (HMOs) within the Medicare program to reduce expenditures and to offer beneficiaries the same health care choices available to those under age 65. Under the Medicare risk program, which became operational in April 1985, HMOs can enroll Medicare beneficiaries and receive a capitated payment for providing or arranging for Medicare-covered services.

The report, The Medicare Risk Program for HMOs--Final Summary Report on Findings from the Evaluation, synthesizes the results of 17 impact analyses, case studies, and annual reports prepared over the past four and a half years, placing special emphasis on whether the program has met the goals of cutting costs and increasing efficiency. The study examines the various effects that the program has had; identifies the types of beneficiaries, HMOs, and market areas for which the program had the greatest impact; and assesses reasons why the program either succeeded or failed in achieving its goals.

Under the Medicare risk program, HMOs receive a payment that is equivalent to 95 percent of what HCFA would have paid for beneficiaries under a fee-for-service arrangement. HMOs must calculate their expected revenue requirements for providing services, compare the amount to their expected reimbursements, and use any surplus funds to reduce beneficiary premiums or to provide additional benefits at no charge. HMOs also must absorb any cost overruns.

The study determines that, although the initiative is designed to save HCFA five percent relative to the amount the agency would have paid in fee-for-service reimbursements, HCFA's program costs actually have increased by 5.7 percent. Much of the increase in costs has been channeled by HMOs into lower costs and added services for beneficiaries, but the goal of the program was to lower expenditures, not to subsidize beneficiary care. The data also indicate, however, that the potential for cost savings does exist.

Participating HMOs have reduced the number of days beneficiaries spend in the hospital by 16.7 percent; have had no impact on the number of hospital admissions; have slightly increased the likelihood that beneficiaries receive services such as physician visits or physical exams; but have reduced the intensity or frequency of the services. These trends are consistent with HMOs' goals of reducing the number of physician visits to control costs while at the same time encouraging beneficiaries to obtain routine preventive care to avert the need for more expensive services later on.

The HMO plans vary considerably with regard to their features, organization, and structures, but most attract healthier-than-average beneficiaries. Enrollment has increased steadily each year since 1985, but the number of participating HMOs has declined from a peak of 134 to 83 in January 1987. About half of the HMOs are losing money. Administrative costs for functions such as marketing and processing claims significantly reduce HMO profits.

The study concludes that, to make the program more cost-effective, HCFA must adjust HMOs' reimbursements to account for the favorable selection the plans have experienced. This solution could prove difficult because lowering payments might discourage HMOs from participating or cause plans to increase premiums, thus slowing the rate of enrollment. In addition, plans must find ways of enrolling enough beneficiaries to spread their financial risk and fixed costs adequately; reducing administrative expenditures; and holding down the use of health care. Finally, HMOs may need to make changes to become more competitive in the Medicare market.

The study was conducted by Mathematica Policy Research, Inc., under contract to the Health Care Financing Administration. The study's project officer, James Hadley, can be reached on 410-966-6626. Copies of the executive summary, #4934, are available from PIC.




Baby bottle tooth decay (BBTD) is a preventable disease which afflicts more than 50 percent of American Indian infants and toddlers. BBTD is caused by leaving a bottle with a child at nap or bedtime, or allowing a child to walk around or sit with a bottle during waking hours. Any liquid with fermentable sugar can cause BBTD, including infant formula, milk, fruit juice, and soda. It is estimated that the cost of treating a severe case of BBTD ranges from $700 to $1,200 or higher, if the decay is extensive enough that hospital treatment is required.

The study, Evaluation and Expansion of the IHS/Head Start/CDC Baby Bottle Tooth Decay (BBTD) Prevention Project, evaluates the methods of disseminating the results of an Indian Health Service (IHS) project designed to reduce BBTD at IHS sites where the incidence of BBTD was 15 percent or greater. The BBTD program was an experimental program originally tested in 12 Indian communities during the period 1984-1989. The program is a cooperative effort among three HHS agencies: the Administration for Children, Youth and Families, Head Start Bureau; the Indian Health Service, Dental Program; and the Centers for Disease Control and Prevention, Dental Disease Prevention Activity. Using two main approaches, one-on-one intervention with the caretakers of small children, and a media campaign in Native American communities, the incidence of BBTD in the targeted communities dropped from 57 percent to 39 percent, a 32 percent overall reduction.

Strategies developed and successfully exported included a marketing plan, which outlined appropriate promotional and marketing activities; a support network to transfer technology from the pilot sites to other interested groups; a policy and procedures manual; a technical assistance hotline; a quarterly newsletter format; three training manuals; and on-site training. These techniques were exported to both IHS and non-IHS sites. The following recommendations were included in the report: (1) establish technical consultants to assist new and existing BBTD programs; (2) continue to publish the newsletter twice yearly; (3) continue to provide training to those communities interested in starting a BBTD program; (4) continue information-sharing between Native American and non-Native BBTD programs; and (5) continue to coordinate BBTD programs with the CDC.

The study was conducted by the Chemawa Indian Health Center, under a contract with the Indian Health Service. The study's project officer, Leo Nolan, can be reached on 301-443-4700. Copies of the Executive Summary, #4964, are available from PIC.




Requests by homeless families for shelter are increasing. In 28 cities surveyed by the U.S. Conference of Mayors, requests for shelter by families increased an average of 17 percent in 1991. Families with children make up 35 percent of the total homeless population, and 60 percent of those family members are children. In the 28 cities surveyed, seven of eight representatives of city homeless coalitions said there were not enough family shelters in their cities, and two-thirds said their city did not have enough emergency family shelters. Family shelters provide more than simply room and board, with a strong emphasis on equipping families with the skills and services necessary to find and stay in homes of their own. These services include education, child care, job placement, drug rehabilitation, housing assistance, and recreational and self-esteem building programs for children.

The study, Emergency Shelters for Homeless Families, examines the quality of living conditions and services in emergency shelters for homeless families. The study was based on visits to 24 family shelters in eight cities, and interviews with shelter staff and 172 homeless families.

Generally, the shelters visited were clean and safe, but cleanliness was a problem at a few. Shelters offered a wide range of services, including Head Start programs, case management services, health care, parenting classes, and housing assistance. However, few shelters offered child care services. This hampered a parent's ability to go on job interviews, find housing, and perform other activities.

Every shelter visited actively encouraged families to participate in Aid to Families with Dependent Children (AFDC) and Food Stamp programs, and some required families to save benefits for rent payments or deposits. When asked why they became homeless, the reason most often cited was family problems, named by 47 percent. Other reasons were eviction, domestic violence, and job loss. Drug abuse was a significant contributing factor to homelessness, with 25 percent of the directors stating that most of their residents abused drugs.

Families find their way into shelters in a variety of ways. Most are directed to a referral agency which matches families with shelters. Two-thirds of the shelters separate teenage and adult men from the general shelter population; some refuse to admit men at all. This caused 10 percent of the families to be separated from at least one member during their shelter stay. This was among several rules shelter residents must abide by. All shelters in the study had published rules, and some means of ensuring each family was aware of them. Violations which could lead to expulsion from the shelter included violence towards residents or staff, intoxication, drug use, possession of weapons, and leaving children unattended.

Generally, the shelters successfully provide a number of critical services to homeless families. However, some areas could be improved. Among these are shelter security and cleanliness, day care services for parents, and methods to prevent family separation caused by denying admission to teen and adult men.

This study was performed by the Office of the Inspector General, Office of Evaluations and Inspections. The final report, #4767, is available from PIC.


Recently Acquired Reports

  • Problems in Determining a Hospital's Level of Uncompensated Care
  • Organ Transplants: Increased Effort Needed to Boost Supply and Ensure Equitable Distribution of Organs
  • Estimates of the Impact and Cost of HIV Prevention in Injection Drug Users
  • Community Models of Coordination in Primary Care Programs



The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research and; policy-oriented projects conducted by HHS as well as other Federal departments and agencies. The PIC on-line database provides project descriptions of these studies. It is available on-line at: Inquiries regarding PIC services should be directed to Carolyn Solomon, Technical Information Specialist, at 202-690-5694. Or E-mail PIC at:

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