In This Issue:
- California's GAIN
- The Impact of Medicare Physician Payment Reform
- Independent Living for Foster Care Youths
- Evaluation of SIPP
GAIN: BASIC EDUCATION IN A WELFARE-TO-WORK PROGRAM -- CALIFORNIA'S GREATER AVENUES FOR INDEPENDENCE PROGRAM
California's statewide Greater Avenues for Independence (GAIN) program, which began in 1986, is targeted to Aid to Families with Dependent Children (AFDC) recipients. For those recipients who are determined to need basic education, participation in basic education activities is a condition of receiving assistance.
The report, GAIN: Basic Education in a Welfare-to-Work Program, presents findings about the operations and educational effects of the program in five California counties (Alameda, Los Angeles, Riverside, San Diego, and Tulare). In addition, program operations only were assessed for Butte County. These six counties account for more than one-third of the state's GAIN caseload, and for more than one-half of its AFDC caseload.
As a program mandating basic education for large numbers of people, GAIN was an important precursor of federal welfare reform legislation, the Family Support Act of 1988 and its centerpiece, the Job Opportunities and Basic Skills (JOBS) program. The report states that the results of GAIN are particularly important to the nation as a whole because California has the country's largest AFDC caseload and because GAIN is the most ambitious of all the states' JOBS programs.
GAIN is overseen by the California Department of Social Services (CDSS) and is administered by the counties. AFDC recipients are sorted into two treatment streams based on their education and skill levels. Those without a General Educational Development (GED) certificate or high school diploma, those who fail to achieve a minimum score on reading and math tests, and those who are not proficient in English are determined to need basic education and are required to attend a basic education program. These participants may elect to engage in a job search activity prior to enrollment; however, those who do not find employment must enroll. Three types of education are available through GAIN: Adult Basic Education (ABE) (remedial education for those at an 8th-grade or lower level); GED preparation for those whose academic skills are strong enough to allow them to study productively for the GED test; and English as a Second Language (ESL). Recipients who are not deemed to need basic education must participate in a job search before entering into other activities. Those who do not find employment through the job search must undergo an employability assessment which is designed to help them choose their next activity: skills training, vocational or post-secondary education, on-the-job training, or unpaid work experience. Any recipient who does not participate in his or her assigned activities is subject to a sanction (a reduction in the welfare grant).
The study uses an experimental research design where registrants are randomly assigned to either a control group or an experimental group. This report is based on a sample of more than 2,500 welfare recipients who met GAIN's criteria for needing basic education. The sample includes both single heads of households with children age 6 and older (typically mothers) and heads of two-parent families (typically fathers). These recipients became members of the research sample between March, 1988 and June, 1990. The study uses field research, casefile data, and a survey and literacy test which were administered two to three years after participants became part of the research sample.
The report finds that all counties provided basic education activities on a large scale, typically using the public schools to deliver services. The schools enrolled recipients, provided them with opportunities to learn, and monitored their attendance and performance. In San Diego County, a new county-wide education program was instituted to serve GAIN participants exclusively.
Fifty-eight percent of GAIN registrants who were in need of education were referred to a basic education program. Of these, seventy percent actually attended such a program. Non-participation was allowed if registrants were temporarily excused, were referred to job search activities, or were continuing in other educational or vocational training in progress before GAIN began. The average GAIN participant attended educational activities for eight months within a two-to-three year follow-up period. However, their attendance was inconsistent: participants attended class for only about sixty percent of their scheduled time, despite extensive monitoring.
Overall, the GAIN program had positive impacts on GED attainment, but inconsistent effects on literacy test scores. In four of the five counties that were evaluated for educational impacts, program registrants received the GED at statistically significant rates, with Tulare County producing particularly substantial impacts. However, GED receipt was concentrated among individuals with the highest levels of literacy when they entered the program, while those at lower literacy levels tended to participate in ABE, rather than in GED preparation. In San Diego County, GAIN produced large and statistically significant impacts on participants' literacy test scores. However, no other county produced measurable impacts on recipients' literacy levels, dissipating the impact when all counties were considered. Those participants who increased their basic literacy skills were, as in the case of GED attainment, those at higher skill levels upon entry to the program.
The results from Tulare and San Diego Counties indicate that it is possible for large-scale mandatory JOBS programs to produce substantial impacts on GED receipt and basic skills levels. However, the fact that other counties did not produce similar results, indicates that significant effort may be required to identify, implement, and maintain effective programs.
The report concludes with an assessment of the factors which led to program success, especially in San Diego and Tulare Counties. Here, the nature of the basic education services offered, rather than the amount, appear to have produced positive impacts for participants. Program practices and the content and organization of the education experiences seem to be the catalysts for positive educational consequences. However, the study does not find that GAIN participation produced any significant increases in employment or earnings during the three-year follow-up period for which data is available.
This study was conducted by the Manpower Demonstration Research Corporation and was jointly sponsored by the California Department of Social Services and the Administration for Children and Families within the United States Department of Health and Human Services. The study's agency contact, Karin Martinson, may be reached at (202) 690-7148. Copies of the Executive Summary, # 5464, may be obtained from the Policy Information Center.
REPORT TO CONGRESS: MONITORING THE IMPACT OF MEDICARE PHYSICIAN PAYMENT REFORM ON UTILIZATION AND ACCESS
In 1989, the Omnibus Budget Reconciliation Act (OBRA 89) instituted the most significant changes in Medicare physician payment policy since the beginning of the Medicare program in 1966. These changes have three major components: the introduction of a Medicare fee schedule (MFS) implemented in January of 1992; the establishment of limits on physicians' charges exceeding the MFS amount; and the institution of target rates of growth in expenditures for physicians' services. OBRA 89 also mandated that the Health Care Financing Administration (HCFA) monitor the impact of these changes on access to care.
The report, Monitoring the Impact of Medicare Physician Payment Reform on Utilization and Access, responds to this mandate. It measures five indicators of access to care, such as ambulatory visit rates, the percent of the population living with an untreated health conditions, the use of preventive services, hospitalization rates for ambulatory-sensitive conditions, and the use of referral-sensitive procedures, for eight vulnerable subgroups (those living under the poverty level, those dually eligible for Medicare and Medicaid, black beneficiaries, disabled beneficiaries under age 65 and beneficiaries age 85 and older, those without supplemental health insurance, those living in Health Professional Shortage Areas (HPSAs), and those living in areas expected to experience the greatest decreases in Medicare fees).
The report addresses three major issues. First, it examines whether the MFS has produced the kinds of payment shifts anticipated with regard to the specialties of physicians serving Medicare patients and in the distribution of payments between office visit services (evaluation and management) and procedure services. Second, the report determines whether the MFS has caused new barriers to access for vulnerable populations and third, the impact of the MFS on physician practices.
In order to answer these questions, the report uses both Medicare administrative data and survey data. Admini-strative data is examined on a quarterly basis using a monitoring system developed by HCFA. This system contains three analytical files. The beneficiary-based file monitors rates of use of physicians' services for the total population, for demographic subgroups, and for geographic areas. The physician/supplier procedure summary file monitors aggregate changes in services and Medicare payments, within various physician specialty or supplier designations, across geographic areas, and by place of service. Finally, the physician file which covers over five percent of all United States physicians monitors trends in physicians' practices. Survey data from the Medicare Current Beneficiary Survey (MCBS) and the National Health Interview Survey (NHIS) are used to supplement the Medicare administrative data. For example, data on beneficiaries without supplemental health insurance or those in poor health is included in the MCBS or the NHIS, while it is absent from administrative data.
The report finds that, after the institution of the MFS, changes in allowed charges by type of service, by physician specialty, and by site of care did occur. Between 1991 and 1992, total allowed charges for physicians in primary care rose thirteen percent, for those in medical specialties by three percent, and for those in surgical specialties fell by four percent. Furthermore, total allowed charges for visits and consultations increased abruptly relative to total allowed charges for procedures. Medicare charges for non-physician services, which are not covered by the MFS, also increased substantially (by 13.5 percent). Allowed charges for services delivered in an inpatient setting have decreased substantially.
The report finds no evidence that the MFS has raised new barriers to physicians' care for vulnerable populations. However, the evidence does show that vulnerable populations face many barriers to care. The disabled are more likely than the aged to have untreated medical conditions, reflecting their greater rates of chronic disease and continuing care needs. Black beneficiaries, those residing in rural or poor areas or HPSAs have lower ambulatory visit rates, lower preventive services rates, higher rates of hospitalization for ambulatory-sensitive conditions, and lower rates of referral-sensitive procedures. These barriers to care were in place before the MFS was instituted, and are related to beneficiaries' life circumstances, rather than to the MFS.
An examination of the HCFA physician practice monitoring file for 1991 and 1992 in 18 states shows that the MFS has had an impact on physicians' practices. For example, between 1991 and 1992, average allowed charges per physician in primary care specialties increased ten percent. For those in medical specialties, they increased by two percent, and for those in surgical specialties, they decreased by three percent. The MFS has also resulted in increased Medicare caseloads for primary care physicians, medical specialists, and surgical specialists.
The report concludes that the MFS is associated with the types of payment changes expected; there is no evidence that implementation of the MFS resulted in new barriers to care; and there were changes in physicians' practices (including the assignment rate and billing amounts for unassigned claims).
This report was conducted by the Health Care Financing Administration. The study's agency contact, Marian Gornick, 410-966-6687. The Executive Summary, # 5493, is available from the Policy Information Center.
INDEPENDENT LIVING FOR FOSTER CARE YOUTHS: STRATEGIES FOR IMPROVED ACF MANAGEMENT AND REPORTING>
The Administration for Children and Families (ACF), through the Title IV-E Independent Living Program (ILP), assists states in preparing current and former foster care adolescents for independent adult life. The program supports youth in their attempts to find employment and housing, achieve positive social relationships, perform daily living activities, and live independently of public support.
This report, Independent Living for Foster Care Youths: Strategies for Improved ACF Management and Reporting, is intended to assist ACF in its efforts to improve its management and program reporting strategies for the program.
Created in the Omnibus Budget Reconciliation Act of 1985, the federal ILP provides funds to states, which must reapply for them each year. Applications must include a description of the services and activities the state plans to carry out; how the state will build on previous years' activities; the number of eligible youths and the number of expected participants; and a description of the state's current efforts. Each state must also submit a year end program report. The program supports educational activities, training in daily living activities, individual or group counseling, service coordination, needs assessments, and other activities. States have flexibility in using program funds in most areas, but may not use funds to pay for room and board. Funds must also supplement, not replace, existing expenditures.
ACF requested suggestions on ways to improve its management strategies for the federal ILP, which received permanent reauthorization through the Omnibus Budget Reconciliation Act if 1993, effective October 1, 1992. The report recommends two broad strategies to attain this goal. First, ACF should restructure its ILP application and program reporting procedures. Second, it should focus its management and program reporting requirements on information sharing. Each recommended strategy includes several options for ACF's consideration.
The current ILP application and reporting procedures do not support state planning and inhibit ACF from gaining an accurate picture of state ILP efforts. The application process for ILPs is not part of a state's Title IV-B joint plan for child welfare services, causing some states to compartmentalize their planning. Furthermore, the timing of the application and awards process can be a obstacle to good planning. ILP funds are not awarded until the middle of the fiscal year. Since many states are unable to provide any program services until the funds are in hand, this timing of the grants poses a problem for contractors and others dependent upon program continuity from one fiscal year to another.
There are also problems with program reporting. For example, there is little linkage between state applications and reports, making it difficult to determine whether states have carried out their plans. ACF oversight is further complicated because states use different definitions of terms in their applications and reports. Also, the application and program reports have not focused adequately on program performance and outcomes, relying instead on descriptions of activities. Many of these reporting problems may be traced to ACF's broad direction to the states.
The report identifies several options for addressing these problems. First, ACF could support better state planning by: (1) requiring states to create consolidated plans for child welfare services which include independent living programs; and (2) establishing measurable goals and targets and reporting on their progress in meeting them. Also, ACF could facilitate better state planning by adjusting the timing of the grant awards so that they are available at the beginning of the fiscal year.
The ILP is a formula grant under title IV-E. Each fiscal year's grant is paid out in quarterly payments, and must be spent by the end of the fiscal year following the fiscal year in which the award was made.
Second, ACF could strengthen ILP reporting mechanisms by: (1) having states retain a separate focus on ILPs in their consolidated state plans; (2) providing states with a simple, standardized form for reporting aggregate information; (3) utilizing the capabilities of the Statewide Automated Child Welfare Information Systems (SACWIS) and the Adoption and Foster Care Analysis and Reporting Systems (AFCARS); and (4) encouraging electronic reporting specifically for ILPs.
Third, ACF could take steps to improve the content of the data which are reported by: (1) establishing a standard, basic data set for ILPs; (2) facilitating the development of clear definitions of ILP terms; (3) collecting more detailed budget data through the program reporting mechanism; (4) soliciting information on effective practices and innovations; and (5) developing performance and outcome measures for ILPs.
The report recommends a second broad strategy to facilitate information sharing between ACF and the states and between states. The report identifies several options. ACF could make a concerted effort to facilitate states' access to information by conducting research and evaluation projects, by maintaining an information clearinghouse, by awarding technical support contracts, and by providing training and support to its own staff.
ACF generally concurs with the findings in the report and with the two broad strategy recommendations outlined in it.
This report is based on a study conducted by the Office of Inspector General. Copies of the report may be obtained directly from OIG's Boston regional office. Please phone (617) 565-1050, or fax (617) 565-3751. The OIG identification number for the report is: OEI-01-93-00090.
EVALUATION OF HHS SERVICES INTEGRATION PILOT PROJECTS
The system for delivery of human services is in need of reform. There is no single point of access to services, making eligibility determination difficult. The system's complexity fosters a sense of powerlessness and dependency in clients. Accessing services may be difficult; and, since programs may have conflicting goals or may have their services sequenced inadequately, clients may be overwhelmed by the services they do receive.
In 1984, Congress authorized the Services Integration Pilot Projects (SIPP), a program intended to address these difficulties. Five states, Arizona, Florida, Maine, Oklahoma, and South Carolina, were awarded SIPP grants after a competitive bidding process. Each state was awarded a 12-month planning grant, a 17- month implementation grant, and a 13-month operations grant.
The report, Evaluation of HHS Services Integration Pilot Projects, consists of eight volumes: an Executive Summary, a cross-site analysis and evaluation report, an exemplary practices report, and case studies of each of the five participating projects.
Although Congress authorized SIPP, it did not appropriate any funds for this purpose. Thus, funding had to be found within Department of Health and Human Services (HHS) budget. HHS also sought and received funding contributions from the Departments of Labor and Housing and Urban Development (HUD). Nevertheless, some uncertainty about funding for subsequent years of the project continued, and affected the states' momentum. Moreover, the authorizing legislation required that the demonstration sites implement nine specific elements aimed at improving administrative practices and procedures that traditionally have been considered barriers to services integration. For the most part, the implementation of these elements was limited. HHS did not enforce their full adoption; instead, it urged states to develop services integration strategies that were most likely to increase client self-sufficiency.
Each of the five SIPP state demonstration projects had different operational features and target groups. Arizona's Community Services Integration Project, tested in Flagstaff, was administered through the state's central human services department, as was the case in every state except for South Carolina. It was targeted to families with incomes below the poverty line, especially those receiving Aid to Families with Dependent Children (AFDC), and was intended to increase client self-sufficiency.
The Florida Unified Administrative System (UAS) was designed to integrate services to the elderly in two communities, one urban and one rural. It sought cross-agency case management, removing existing barriers to services through pooling of funds and waiving state and federal regulations, and implementation of community-based unified administration. It too was intended to promote the self-sufficiency of its elderly clients.
The Family Services Integration Demonstration (FSID) in Maine was targeted to pregnant and parenting teens and was expected to integrate income maintenance, social services, employment, health, and nutrition services for this group. A major program goal was to integrate eligibility determination processes for all the programs. It also sought higher levels of efficiency, effectiveness, accountability, and cost benefits.
Oklahoma's Integrated Services Project (ISP) attempted to teach clients the skills necessary to negotiate the service delivery system on their own. The project used a formalized case management system which emphasized networking and the involvement of public, voluntary, and private sector agencies in five rural counties. It served all low-income, multi-problem families in the five demonstration counties.
Finally, South Carolina instituted the unique Human Services Integration Project (HSIP). HSIP was a statewide undertaking to reform and integrate services provided by eleven different state agencies. The program was managed by a State Reorgani-zation Committee, thereby removing its administration from the rivalries and confusion of the state umbrella human services agency. The program had two subsystems: service delivery and management. It sought the involvement of all public and private sector agencies and groups.
Of all the state efforts, those in Oklahoma and South Carolina were most successful. Their service integration programs have become institutionalized, and are continuing to expand. At the other end of the spectrum, Arizona's program was least successful. After SIPP funding ended, the program was discontinued. Several factors contributed to the program's poor performance: (1) political turmoil on the state level eliminated support for the program; (2) the program was not able to show statistically significant results; and (3) local providers were never fully involved in the project.
While states had widely varying levels of success with SIPP, several issues and difficulties are common to them all, as are key successes. The report finds that the implementation of the nine legislatively mandated elements for the program were difficult for all sites. In particular, the mandates regarding administrative changes, such as standardized accounting and budgeting procedures and purchase-of-service agreements, require substantial changes at the state level. However, states were much more successful at affecting change at the local level, particularly in the area of service delivery. Thus, the mandated administrative changes difficult for states to implement. Furthermore, the report questions the advisability of such legislatively-mandated changes. Specificity on this level may indicate to states that these changes themselves are goals to be worked toward, rather than methods to facilitate the ultimate goal of service integration.
The report also finds that restrictions on how states could use federal funds posed problems for the states. Regulations precluded the use of demonstration funds to pay for delivery of specific services, but allowed the funds to be used for service coordination. While the report finds that these restrictions were in keeping with the goals of the program, the participating states failed to set aside monies to fill identified service gaps. Because service integration efforts are likely to increase the demand for services, states should have made provisions for their delivery.
The relationship between the federal government, represented by the former Office of Human Development Services (OHDS), and the state grantees was not always a harmonious one. While OHDS intended the program to promote client self-sufficiency, four of the states held that this goal was contrary to program mandates. The matter was referred to the Office of the Inspector General (OIG), which supported OHDS. Another difficulty in the federal/state relationship was a misunderstanding about the use of waivers. The grantees were led to believe that the federal government would expedite its waivers process for SIPP projects. However, waiver requests were discouraged by some federal agencies, and no expedited procedures existed, forcing states to abandon extensive plans which were dependent upon their receipt of waivers. In final point of fact, only two waivers were received during the life of the program.
Despite these difficulties, the programs did have some successes in each of the five states. Each site provided case management services to its clients, most efficiently when new case management units were established. Furthermore, states attempted to improve clients' access to services. While co-location of services and provision of transportation between service sites proved to be prohibitively expensive, states used voucher systems, outstationing, and intake generalists to improve access to services. Finally, all sites developed tools which supported case management. These tools, such as common service taxonomies, resource directories, and client tracking systems, were essential elements of SIPP. However, ineffective use of the tools limited the success of some programs.
Another key program success, at least in Oklahoma and South Carolina, was a high level of local involvement in planning. Use of coordinating councils and other local level networks allowed these states to maintain the linkages they had forged during the grant period and to continue the program after the funding ended.
Thus, the report finds that, despite problems encountered in the implementation process, the SIPP effort demonstrated the possibilities of services integration for improving the effectiveness of services by increasing coordination and access to services.
This report was prepared by James Bell Associates and was sponsored by the Administration for Children and Families. The agency contact for this report is Hossein Faris. He may be reached at (202) 205-4922. Copies of the Executive Summary, # 5491, are available from the Policy Information Center.
Recently Acquired Reports
- Case Management in Service Integration: An Annotated Bibliography (PIC ID No. 5307.A)
- Creating Systems of Care for Substance-Using Pregnant Women and Their Children (PIC ID No. 5460)
- Updating the Geographic Practice Cost Index (series: PIC ID Nos. 5764-5764.4)
SERVICES AVAILABLE FROM THE PIC
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: http://aspe.hhs.gov/PIC/. Inquiries regarding PIC services should be directed to Carolyn Solomon, Technical Information Specialist, at 202-690-5694. Or E-mail PIC at: firstname.lastname@example.org