This project encompasses a series of activities aimed at increasing our knowledge of academic health centers' financial status and their ability to sustain the production of such public goods as uncompensated care, teaching, and research. A conference of leading experts was held in September 1998 in order to explore additional, and more consistent data sources for studying this issue. In addition, analyses comparing the performance of academic health centers to other hospitals has been extended through the use of 1997 data and a similar analysis comparing children's' hospitals to other hospitals has been conducted. Finally, we are assessing the possibility that data filed by hospitals with the SEC when they float public bonds will be complete enough to permit further analysis of the financial status and mission related activities of these hospitals.
This is a three-year grant (FY98 is Year 3) sponsored by the Agency for Health Care Policy Research (AHCPR). This study will use large scale decision-analytic models which employ Markov processes to conduct simulations, and to combine it with previous work to estimate survival, quality of life and costs in liver transplantation. The characteristic of this work that distinguishes it from other work in the field is its focus not on the transplant recipient but on the patient with end-stage liver disease (ESLD) who is a candidate for liver transplantation. Decision-analytic techniques will be used to characterize the choices and the probabilistic events associated with the care of the patient with ESLD. The inputs into the model will require the quantitative description of the "natural" history of ESLD patients with and without transplantation in the form of expected survival, quality of life, and resource use, adjusted for clinical characteristics (i.e. severity of illness). The result of the analyses should be the identification of criteria (patient characteristics as a function of the evolution of the severity of disease over time) that will permit the selection of recipients and the timing of the transplant so as to optimize the balance of quality-adjusted life-years to resource use in the population with ESLD.
Grantee: University of Pittsburgh
Completion Date: September, 2000
This project will collect information on current and planned evaluations of telemedicine activities; assess the purpose and methods of such evaluations and the relevance of the resulting or potential findings to federal policy and programs; and develop a conceptual framework for designing such evaluations. Information will be collected through literature searches, interviews and document review at Federal agencies, and site visits to ongoing telemedicine projects. The purpose of the study is to develop a better understanding of how telemedicine evaluations can be designed to better inform and facilitate Federal program and policy decisions.
ASPE coordinates both the HHS Racial and Ethnic Health Disparities project and the Administration's Empowerment Zone and Enterprise Community Initiative. Both initiatives recognize that community-driven strategies are key to success. Leaders of the racial health disparities effort acknowledge that public health education programs tailored for particular community groups may be one component of effective strategies for addressing the target health topics, and a key tenant underlying the EZ/EC Initiative is that the federal government must allow community groups to structure revitalization projects to fit their unique needs and particular circumstances. Also, a significant portion of EZ/EC neighborhood residents are of ethnic and racial minority backgrounds, thus it is likely that those residents suffer disproportionately from health conditions targeted by the disparities initiative.
This project will review EZ/EC strategic plans and interview key EZ/EC leaders and local and State health officials to determine:
- the extent to which current EZ/EC plans/benchmark documents feature projects addressing particular public health and health care access issues, including a synopsis of the health components of individual EZ/EC projects;
- the extent to which local and state public health departments have been or continue to be active participants in local EZ/EC planning and implementation processes, including the reasons why they have or have not been key players in particular EZ/EC processes; and
- the extent to which the racial health disparities target health conditions are prevalent in individual EZ/EC neighborhoods.
The final report should include recommendations of what HHS should do to assist and/or encourage:
- EZ/EC organizations to understand the long-term value of addressing health issues in their neighborhoods, and to become active participants with the Administration in addressing these health disparity issues;
- local and State health departments to understand how they could help EZ/ECs address health issues;
- various health components of HHS to become more involved in assisting the EZ/ECs consider health topics.
Since the 1960s CDC has funded state and local health agency immunization activities. HCFA(now known as CMS) is working with state Medicaid and Medicare agencies toward improving immunization practices at the state and local levels through the Medicaid and Medicare Immunization Resource Guide. While the federal agencies are working to forge a relationship to work to achieve immunization goals it is not clear how these efforts will impact state agencies and the outcome of improved immunization rates and decreased vaccine preventable diseases.
The project in phase 1 will do case studies in up to 5 states to learn how states (in public health, Medicaid and Medicare) are working on the on immunization goals using the guidance and technical assistance provided by the federal government. This phase will highlight the status quo and understand the extent to which states are planning to incorporate HCFA(now known as CMS)'s guidance into their activities.
In phase 2 (FY2000 funding), the project will be in up to 3 of the states and will work with these states to take this activity to the next level. For example, some of the issues we could work with states on are: holding FFS Medicaid the same similar standard of immunization coverage as Medicaid managed care; and identifying and implementing appropriate outcome measures for immunization (e.g. vaccine-preventable disease rates). The goal of the project is to evaluate how states use federal guidance toward improving immunization status and further to assist the federal government on continuing to implement this work with states. This project would be done through a task order. Both CDC/National Immunization Program and HCFA(now known as CMS) would be involved in the project.
Because of the controversial nature of FDA's regulations regarding Direct-to-Consumer Advertising regulation, FDA would like ASPE support in a project to determine if consumers are getting information on both risks and benefits from prescription drug advertisements. FDA needs the information to respond to both consumer and physician groups. The project would conduct focus groups to examine what information consumers are getting from advertisements. Depending upon the results generated from focus groups, a second project funded next year could conduct experiments that would measure consumer perceptions of different warning statements and advertising techniques.
This evaluation is conducted in collaboration with the Substance Abuse and Mental Health Services Administration (SAMHSA). The purpose is to assess the impact of the PATH program, a categorical grant program where states and territories receive funds to assist individuals with severe mental illness and/or addictions to move from homelessness to mainstream treatment services and housing. A legislative requirement exists to review program operations every three years, and the General Accounting Act of 1996 resulted in a transfer of authority to conduct this activity from GAO to the SAMHSA Administrator.
Contractor: Westat (Subcontractor: R.O.W. Sciences)
Report Availability: Fall 2000
Impact of Managed Care on Individuals with Disabilities: Evaluation of Oregon and Tennessee Medicaid 1115 Waivers
As part of ASPE’s research agenda on examining managed care impacts on individuals under 65 with disabilities, ASPE has worked with HCFA(now known as CMS) to modify two of the existing 1115 wavier evaluation contracts to incorporate a special analysis on SSI disabled in two waiver states, Oregon and Tennessee. The ASPE disability evaluation component is similar to the core HCFA(now known as CMS) evaluation in its examination of impacts on utilization, costs, providers, and beneficiary satisfaction and outcome measure, but focuses on the disabled beneficiary population. ASPE funding is being used to support specific analyses of utilization by major types of disability (mentally retarded, physically disabled, mentally ill) linked to state data bases that provide periodic measurement of disabled individuals in both states. The groups covered bar by states. ASPE funding is also being used to fund surveys of disabled beneficiaries (including children in Oregon), a focus group of providers in Tennessee, a provider survey in Oregon, a detailed longitudinal case-study of 20 disabled individuals in Tennessee, and detailed case-studies of implementation in both states.
The Seafood HACCP Program mandates the application of HACCP principles to the processing of seafood. HACCP is a preventive system of hazard control that can be used by processors to evaluate the kinds of hazards that could affect products, institute appropriate controls to keep the hazards from occurring or minimize their occurrence, and monitor performance of those controls. This program supplants the old FDA seafood inspection system. FDA published the final rule December 1995. The effective date of the program is December 1997. In approving FDA’s Seafood HACCP final rule, the Department committed to evaluating the program. The proposed project would develop an evaluation program to be implemented sometime after the rule’s effective date.
This project has two components. First, it would attempt to assess the major sources of consumer dissatisfaction with health plans, based on the complaints that are files. Second, it would assess implementation of two or three selected consumer protections in a few states that have had such protections in place for several years (at least the ER "prudent layperson" standard and direct access to OB/Gyn, possibly also anti-gag provisions).
(1) Implementation/Enforcement of Existing Legislation -- The same task-order contractor would be asked to contact state health and insurance departments, and state's attorneys general offices, to learn how specified state consumer protection laws are being enforced. Funds permitting, the contractor would also interview health plans (and possibly fully insured employers) in the same states on the same subjects.
(2) Identifying Key Consumer Complaints -- A task-order contractor would compile and categorize the nature of consumer complaints about health plans from as many sources of complaints as possible: state insurance and health departments, external appeals organizations, advocacy organizations, and others. As part of this effort the contractor will inquire about related issues such as: How to States handle complaints from consumers in ERISA regulated plans? Are complaints being used to improved health plan operations (is there feed-back to plans)?
The Medicaid program has undergone substantial changes over the past decade, include numerous eligibility expansions, a dramatic growth in the role of managed care, and a shift from its traditional link to welfare eligibility. Many of these changes have been driven by factors outside of Medicaid – budget considerations, welfare reform, market factors, and the like. As part of policy discussions about Medicaid, it would be helpful to engage in some long-range thinking about how the program might evolve in the future (in both the short term and long term). This project would call for an expert to develop a broad paper on future scenarios for the Medicaid program (or two experts to develop separate papers). The paper might include a look at such issues how eligibility criteria, the degree of reliance on managed care, and role of plans and providers that serve primarily Medicaid beneficiaries.
With the Institute of Medicine, this project is studying trends in medical technology and changes in the health delivery system, including a historical review of major changes and assessments of the future from the research community. This will include information on what we can expect technology to achieve and the uses for which the medical community will recommend this technology. This information can then be used to reexamine assumptions about changes in demographics, disability, and life expectancy.
Comparing health care use of uninsured decliners to uninsured and insured workers. One theory for why certain people decline offered health insurance is that it is not a good deal for them-- especially young, single, relatively low wage workers. To test this theory, we will compare health care use for workers who decline employer offered insurance to other uninsured workers and to insured workers using the NHIS and controlling for age, health status, income and other factors that are related to health care use.
Understanding Health Plan Accreditation and Its Potential to Promote the Consumer Bill of Rights and Responsibilities
This project's purpose is two-fold: (1) to provide policy and regulatory staff in the U.S. Department of Health and Human Services (HHS) with an in-depth understanding of the aspects of the health plan accreditation process most closely related to the Consumer Bill of Rights and Responsibilities (CBRR); and (2) to determine the extent to which health plan accreditation fosters implementation of the CBRR.
This understanding will inform broad policy debates about promoting consumer protection in the private health plan market. The study's results will provide useful feedback to the individuals and entities involved in developing the CBRR – by illustrating difficulties that accrediting organizations and health plans may face in operationalizing CBRR provisions. In addition, the study's findings will help regulators within the Health Care Financing Administration (HCFA(now known as CMS)) refine quality standards and quality improvement measures applicable to Medicare+Choice health plans.
[formerly known as Los Angeles Survey of Families and Communities, or LASFC]
ASPE has provided supplemental funds to NICHD for this four-year longitudinal study of families and neighborhoods in Los Angeles County, being conducted by RAND. The L.A. FANS is specifically designed to answer key research and policy questions, including questions related to the effects of welfare reform at the neighborhood level. ASPE’s contribution will be used to expand the data collected in the first wave of the L.A.FANS on health care utilization, health insurance, and health status.
The L.A.FANS will be carried out in a representative sample of 65 neighborhoods in L.A. County and about 50 households in each neighborhood, for a total of 3,250 households. The survey will also include an additional sample of 500 cases distributed across poorer neighborhoods. The project includes both a household survey with adults and children, and a neighborhood survey with key informants and social service providers. Data collection will take place in 2000, 2001, and 2003.
The first wave of the survey began in April 2000 and will continue through November 2000. Release of the public use data from wave 1 is anticipated in January 2001.
The burden of disease in a population consists of the morbidity and disability experienced be its members, their psychological perception of the adequacy and effectiveness of the care they receive, and of the resources expended for the maintenance of their health. The essence of medical care is to devise the trade-offs among these components that will most enhance overall health. The objective of the proposed project is to develop and evaluate analytic techniques that will permit (a) the construction of an integrated measure of the burden of disease based on the explicit assessment of what trade-offs are currently accepted, and (b) identify changes in strategies to optimize the mix.
The purpose of this project is to further the Department’s understanding of the role it plays or could potentially play in disseminating and implementing research findings related to health promotion and disease prevention, illuminate the means by which HHS evaluates the impact of its dissemination/translation efforts, and identify areas in which the HHS role can be enhanced.
Work conducted under this contract will further our understanding of the mechanisms that affect the movement of health promotion and disease prevention research findings from one stage to the next and the role HHS plays in each of these stages. By identifying the relevant mechanisms that affect the dissemination process, HHS will be better able to successfully disseminate the research findings which have public health and clinical importance. In addition, HHS has a direct stake in effective dissemination of research findings for purposes of producing improvements in Departmental programs such as Medicare and Medicaid and to improve the quality of life for the people served by programs such as Head Start.
The main topics to be addressed in this study include:
- What is HHS’s role in each stage of the dissemination process? Which HHS Operating Divisions (OpDivs) and Staff Divisions (StaffDivs) play a role and at which stages? How do they communicate with each other to share findings, strategies for dissemination and implementation?
- What are the priorities used by HHS to select which findings will be given resources for dissemination activities? Is it the possibility of successful policy implementation? Potential to relieve human suffering? Cost savings likely to accrue upon implementation? Potential to improve the quality of life for a certain population?
- How is the target audience identified? ( Does this include the general population? Populations specifically at-risk? Providers? Insurers? Policy makers?) How does the dissemination strategy vary depending on the characteristics of the target audience? Is a different strategy required when the means of reaching the audience (and evaluating the success of the dissemination) is funded by a project grant as opposed to a block grant or entitlement?
- What are the features of effective dissemination? (Simplicity of the findings to be disseminated? Sophistication and/or comfort level of the target audience with the message to be communicated? Potential benefits to stakeholders -- consumers, insurers, industry?) Is a different strategy needed when disseminating “virgin” information, as opposed to information that would overturn current belief?
- What dissemination strategies are appropriate when the scientific evidence is uncertain or conflicting? How could incorrect, misleading, or inappropriate information be countered?
- What are the barriers to effective dissemination? How can these barriers be overcome?
- What are examples of successful dissemination strategies that are culturally and linguistically appropriate? To what extent do HHS dissemination efforts address populations for whom literacy is a barrier?
- To what extent has HHS formed partnerships with other organizations to further dissemination and implementation? How could these partnerships be enhanced?
- How does HHS evaluate the impact of its dissemination efforts? How could HHS improve its dissemination process?
- What are particular applications of these issues in the context of Federal health care programs such as Medicare and Medicaid?
Expected Completion Date December 2000
The Demand for Medicare Supplement Insurance has changed in recent years. The number of Medicare beneficiaries in HMOs or other Medicare+Choice plans has increased in recent years, which has affected both the aggregate demand for the insurance and the demographics of those who purchase it. Moreover, employer provided benefits for retirees has been declining. The collective effect of these changes may be significant, but currently there is little analysis available to determine whether or how the Medicare Supplement Insurance market has changed. However, better information about how this market behaves and how it is changing over time can help the Department develop policies that will ensure stable health care financing for the elderly.
Our funding will support three research papers; 1) an examination of variation of the Med-supp market among states; 2) the effect of HMO penetration on Med-supp markets; and 3) the demand for prescription drug benefits in the Med-supp market. Collectively, these papers should provide a much better understanding of how this market has been operating, and thereby provide a better understanding of how new Medicare policies might affect it.
This office is currently funding a project that has analyzed data from several major Departmental surveys (i.e., the National Longitudinal Study on Adolescent Health [Add Health]; the Youth Risk Behavior Survey [YRBS]; and the National Survey of Adolescent males [NSAM]), and produced a series of data tables and three Research Briefs regarding incidence and prevalence estimates for various clusterings/co-occurrences of risky behaviors among youth, as well as the clustering of risk and "positive" behaviors.
This followup would seek to conduct further and more detailed analyses on some of the findings emerging from the existing project. These additional analyses would then be presented in a series of working papers that would be disseminated to researchers, policy makers, Federal and State program staff in child and youth areas, and other relevant stakeholders.
The purpose of this project is to investigate how states are monitoring and evaluating the experience of children with special health care needs enrolled in Medicaid Managed care. Research findings will be used to refine the standards HCFA(now known as CMS) requires states to meet in order to enroll children with special health care needs into capitated Medicaid managed care plans, and to assess state ability to meet these standards.
Background: The experience of children with special health care needs in Medicaid managed care is of mounting policy importance as the proportion of states enrolling these children in managed care grows. According to the National academy for State Health Policy (NASHP), the percentage of states using risk-based managed care for SSI children increased from 32% to 71% from 1990 to 1998. As the enrollment number grow, there is increasing concern that Medicaid plans and providers are not meeting the complex needs of these children. Policy makers are interested in addressing this issue but are hampered by the lack of concrete data or information related to the experience of this population in Medicaid managed care.
To respond to these issues, HCFA(now known as CMS) has developed interim review criteria that will be applied to all upcoming 1915(b) waiver applications and renewals from states. The criteria establish requirements regarding definition, identification, tracking, and access to care for children with special health care needs enrolled in capitated managed care arrangements. The criteria are currently at a developmental stage. This study will help HCFA(now known as CMS) and the states move forward with this important effort by providing critical information about current state activity and insights as to how these criteria can be refined, improved and operationalized.
There has been growing interest in the service utilization and expenditure patterns of individuals enrolled in both Medicare and Medicaid (i.e., dual eligibles). In order to provide important data on these populations, two ASPE offices (HP and DALTCP) collaborate with HCFA(now known as CMS) to fund a project that will link Medicare and Medicaid data in 10-12 states. This is an effort to develop a uniform database that can be utilized by both States and the Federal Government to improve the efficiency and effectiveness of both acute and long-term care services provided to these populations. More specifically, the project strengthens the ability of HHS and States to develop effective risk-adjusted payment methods for dual eligibles, and further understanding of how interactions between the Medicare and Medicaid programs affect the access, costs and quality of services received by dually eligible beneficiaries.
The Office of the Assistant Secretary for Planning and Evaluation (ASPE) engaged The Lewin Group to assess the capacity of the infectious disease surveillance system in the United States. The purpose of the study was to identify major gaps in infectious disease surveillance preparedness and to develop an investment framework to address the gaps identified. This multi-part study included a comprehensive literature review, interviews with infectious disease experts, two expert panel meetings, and site visits to three public health jurisdictions. The final investment plan included detail information on specific investment strategies to ensure adequate capacity to identify and understand infectious disease threats.
Safety Net Project: Exploring State Use of Medicaid Disproportionate Share Funds to Enhance Provision of Care to Uninsured
This project will study the cases in which states redirected or changed their use of Medicaid DSH funding streams to strengthen safety net infrastructure in communities within their states; used DSH funds to increase the services available to uninsured populations; or provided insurance to previously uninsured individuals through DSH.
States began using Medicaid provisions concerning provider taxes and provider donations to generate additional funding Medicaid matching funds in the late 1980's. The basic mechanism was that providers would transfer funds to state accounts for the provision of Medicaid services; the Federal Government would match the funds; the state would return the original donation or tax to the provider in the form of a state Medicaid payment; the additional Federal funds generated would be used by the state to a) provide additional funds to providers, b) retained by the state to build a surplus, c) transferred to other state accounts (e.g., build roads); or d) allow for general tax relief. Congress placed limits on these practices in the early 1990's by requiring that no hospital could receive DSH funds in excess of its uncompensated care expenditures and any hospital receiving DSH funds had to have at least a 1% Medicaid caseload, by requiring that taxes had to be broad based and not financed by limited levies on providers, and by limiting DSH spending as a percentage of a state's total Medicaid budget. State's therefore have DSH caps under current law. Some state's are above their DSH caps in which case they can not receive additional DSH funds until their base Medicaid expenditures grow, and others are below their DSH caps which means they can generate additional DSH expenditures up to their caps. In a recent study of DSH, Urban Institute indicated that states have been retaining fewer DSH dollars at the state level and that local and county hospitals received more DSH funds and state hospitals fewer.
The Department often requires the capacity to collect data for evaluating and monitoring the impact of changes in the health care and welfare system and various programs such as health insurance, at the state level, as well as at the national level. Most of the Department’s surveys are primarily designed to collect data at the national level. This project investigates the feasibility of approaches to obtain state-based estimates from the current National Health Interview Survey (NHIS) either independently or in combination with a telephone-based data collection supplement that uses dual frame estimators.
Does differential health status affect workers’ decisions to decline offers of employer-sponsored health insurance?
The purpose of this project is to follow-up on a previously-awarded ASPE task order which examined the characteristics of workers who decline offers of health insurance coverage from their employers and remain uninsured (“decliners”), compared how the decliner population might have changed during the 1990s, and examined how decliners compare to other relevant groups (i.e., workers who take-up offers (“takers”) for employer-sponsored insurance (ESI) and workers not offered health insurance coverage), with a particular focus on variations in health status and health conditions. The analytical work consisted of producing descriptive statistics of those worker groups using data from the National Health Interview Survey (NHIS) for 1993, 1994 and 1997.
The follow-up project will build on this initial analysis by developing multivariate models of demand for health insurance coverage, in order to better understand the relative importance of price, health status and health conditions in a worker’s decision to accept or decline an offer of ESI. These models will control for a variety of health, demographic and employment factors, as well as develop separate estimates for single workers with no dependents who are expected to buy single policies and for "family candidates," i.e., workers who are married, have dependents, or both.