Performance Improvement 1996. Office of the Assistant Secretary for Planning and Evaluation


MISSION: To provide analytical support and advice to the Secretary on policy development and assist the Secretary with the development and coordination of HHS-wide program planning and evaluation activities.

ASPE Evaluation Program

ASPE functions as a principal advisor to the Secretary on policy development and conducts a variety of evaluation and policy research studies on issues of national importance. ASPE is also responsible for HHS-wide coordination of legislative, planning, and evaluation activities. In its evaluation coordination role, ASPE does the following:

  • Provides annual guidance to all HHS agencies and staff offices about evaluation priorities, procedures, and review requirements.
  • Reviews evaluation priorities proposed by HHS agencies, providing advice about the focus or method of proposed projects and identifying opportunities for collaboration and effective use of resources.
  • Prepares planning and summary reports on evaluation activities as required by Congress.

Through the departmental evaluation planning process, ASPE has the capacity to identify crosscutting program or policy issues of particular concern to the Secretary and specific program and policy areas not covered by HHS agency evaluation plans. In these instances, ASPE initiates evaluations or collaborates with the agencies to conduct evaluations or policy assessments. For example, in recent years ASPE has initiated projects to develop cost estimates for health financing issues in general and specifically for Medicare and Medicaid programs; the effects of managed care expansion on public health infrastructure; welfare- to-work approaches; long-term care alternatives; and studies evaluating alternative services for children at risk of harm from drug abuse, crime, abuse, and other pathologies.

Another continuing ASPE evaluation objective is to support and promote the development and improvement of databases that HHS agencies and ASPE use to evaluate health care programs and health trends. ASPE provides support to the HHS Data Council charged with integrating key national surveys, such as linking health status indicators with indicators of well-being. HHS needs more comprehensive data sources to assess the anticipated transformation in health and human services.

Finally, ASPE uses evaluation funds to promote the effective use of evaluation-generated information in program management and policymaking. The latter is accomplished through the dissemination of evaluation findings and other activities such as providing technical assistance to agencies in the development of performance measures.

Summary of Fiscal 1995 ASPE Evaluations

During 1995, ASPE completed 28 studies and reports on a number of issues that provided information useful to the Secretary and HHS divisions for purposes of program planning and budget and legislative development. A description of some of those completed studies that have broad potential application follow.

Adolescent Sexuality and Parenthood

Several studies were aimed at providing the Department with an expanded understanding of the causes, impacts, and possible ways to address the pervasive national triad of adolescent sexual activity, pregnancy, and teen parenthood. One study examined prevention and intervention strategies designed to reduce adolescent pregnancy and parenthood. A second report summarized recent research on adolescent sex, contraception, and childbearing. The report summarized the factors that lead to teenage childbearing. The varied antecedents of sexual activity include biological factors, race and gender, family characteristics, use of alcohol or drugs, and other behavioral factors. The studies documented the increased rate of sexual intercourse among teens. The earlier the age of sexual initiation, the more likely the experience is coercive and the more likely the teen will become pregnant or contract a sexually transmitted disease (STD). Another study analyzing the increases in nonmarital births found that one-third of all births occur outside of marriage, with teenagers accounting for about one-half of all nonmarital births; and a smaller proportion of nonmarital pregnancies are ended in abortion. Most parents in nonmarital births are disadvantaged before the birth.

Health Information

As the pressure on expanding data-collection systems continues and the ability to store, manipulate, and transmit such growing amounts of information accelerate, it becomes more important to protect the privacy of this information. ASPE supported a task force on the privacy of private sector health records. The task force examined the extent of the problems with the collection, storage, and use of health information in the private sector. The task force also examined the social, legal, and economic issues affecting the privacy of people who use the health care system. The report recommended a coordinated Federal policy on medical records, confidentiality, universal identifiers, effective security standards and guidance, the establishment of a data- protection entity, and an education program about the issue.

Substance Abuse

Substance abuse problems blight the lives of individuals served by a number of HHS programs. It is therefore important to increase understanding of the etiology of substance abuse and of effective modes of intervention. One study looked at patterns of substance use and substance-related impairment among recipients of Aid for Families with Dependent Children (AFDC). It found that while AFDC recipients have higher rates of substance use and substance-related impairments than the general population, the vast majority of substance users and impaired people do not receive AFDC. A second study of substance abuse among women and parents also examined the number of children potentially at risk because of parental drug abuse. The study also found that children of drug-using parents tend to be younger than children overall and women and men with young children in their homes tend to report one-half as much illicit drug use as those with no young children at home.

Transition to Work

Another area of significant concern and interest is the movement of individuals from various dependent arrangements, including welfare, into employment. Three complementary studies were carried out to learn more about barriers to and models for facilitating transition of disabled individuals to work.

One study reviewed literature on barriers and incentives to improving the labor force participation of persons with significant disabilities. The second study evaluated the methods used in transition-to-work demonstration projects aimed at helping schools and adult providers obtain integrated employment, using natural supports for students with very severe disabilities. The report details the barriers encountered by the demonstration sites, such as difficulty locating jobs, difficult funding procedures, transportation problems, and staff turnover.

A third study examined approaches States have taken to move significant numbers of welfare recipients into work-related activities, with the goal of identifying operational lessons for program administrators and policymakers. The report documented strategies States used to increase participation in work, the role of child care in achieving this objective, and how States changed the culture of welfare to have a stronger focus on employment.

ASPE Evaluations in Progress

ASPE currently has 26 studies in progress on a broad range of program and policy areas. The major areas of study include the following:

Assisted Living

ASPE has commissioned a national study of assisted living, or the residential settings that combine adapted housing, assistive technologies, personal assistance, and other supportive services for persons with disabilities. Assisted living is considered an important component of services to the increasingly aging American population and an effective response to the rising costs of nursing home care. The study will examine the role of assisted living from the perspective of consumers, owners and operators, workers, regulators, developers, investors, and others with a stake in the long-term care system.

Board and Care Homes

As many as 1 million mostly elderly or disabled individuals are dependent on personal services and supervision provided by board and care homes. To examine one significant way in which public agencies seek to influence the care provided in these facilities, ASPE is carrying out an analysis of the effect of regulations on the quality of care provided in board and care homes. In addition to raising concerns about the unwillingness or inability of most homes to meet changing resident needs and inadequate staffing ratios, the study's preliminary findings show that extensive regulation did reduce the use of psychotropic drugs and increases operator training and the availability of social aids and supportive devices. However, regulation does not affect operators' requirements for staff training, the availability of licensed nurses, or the cleanliness of the home.

Domestic Violence

Two studies are looking at the costs of domestic violence to the health care system and the domestic violence policy and programs of selected communities. Together, the studies will provide information about the economic consequences of costs of domestic violence to the health care system and will develop an economic model for determining these costs. The studies will also examine how selected communities have built community-based comprehensive family violence programs.

Evaluation of Family Preservation Services

ASPE and the Administration for Children and Families (ACF) are evaluating selected family preservation programs, including placement prevention services aimed at preventing children from entering substitute care, broader family preservation services that may be less intensive and of longer duration than placement prevention services, and reunification services to speed the return of children to their homes after entering substitute care. Measures of program success will include reduced placements of children into substitute care (for preplacement services), successful reunification (for reunification services), improved child psychological well-being, improved child behavior, improved family functioning, and reduced recurrences of child abuse and neglect.

Health Care Technology Assessment

ASPE is preparing current information on the demand for technology assessment. The study will examine the performers of technological assessment, the methods of conducting assessments, the uses of the results, and the unmet needs that might be met by further cooperation between the public and private sectors of health care.

Information Used by Physicians

The purpose of this study is to understand the relationship between the increasing amounts of information that are being produced for physicians and the types of information that physicians actually use. In particular, this study is assessing physician use of available computerized health and medical information sources, such as those on the World Wide Web and the Internet, and how access to such information influences medical practice.

Long-Term Care

It is difficult to estimate how often people who enter nursing homes down their assets and become eligible for Medicaid. Because some elderly people enter nursing homes more than once, a longitudinal study to help provide this information is being conducted.

Managed Care and People With Disabilities

Managed care can provide unique opportunities but also has potential pitfalls for people with disabilities. Research is under way to determine the impact of managed care on access, quality, and satisfaction for people of all ages who experience disabilities. Of particular interest are the experiences of children with disabilities in managed care, best practices in managed care for the disabled, and the impact of extending Medicaid managed care to the disabled population eligible for Supplemental Security Income (SSI).

Moving Welfare Recipients to Work

HHS, with ASPE's assistance, is conducting a comprehensive, multiyear study of the government's principal program for moving people off welfare and into employment--the Job Opportunities and Basic Skills Training (JOBS) program. The evaluation addresses the long-term effects of different welfare reform approaches including whether any approach significantly improves the economic circumstances of the most disadvantaged recipients, the effects of welfare-to-work programs on the children of welfare recipients, and the cost effectiveness of different approaches.

Performance Data

The Federal grants relationships to States in public health are evolving into outcomes-based performance management. A health outcomes-based monitoring approach requires data system development, and several projects are being conducted for that purpose. One project, with the National Academy of Sciences, will work on identifying which results of a performance-based approach can be measured at the State and Federal level and will recommend specific steps that can be taken to improve these measurement capabilities. A related project will develop approaches to obtaining comprehensive baseline and trend data on public health infrastructure. Finally, a third study, building on a Robert Wood Johnson Foundation project, will assess the quality of data that States collect and determine whether a network can be established to share health data among the States and thus improve the health policy decisions they make.

Pharmaceutical Marketplace

The growing influence of managed care has had a profound influence on the pharmaceutical marketplace and has highlighted a number of concerns among pharmaceutical companies, third-party payers, and the Federal and State governments. ASPE is engaged in a project to develop a framework to assess the impact of managed care on the pharmaceutical marketplace, as well as on consumer access to newly developed drugs.

Promoting Father Involvement

Three studies are looking at various aspects of father involvement, especially among fathers who are not living with their children. One study examines the relationship between various child custody, visitation, and support payment patterns and the effect that payment and contact have on child well-being. The second is developing a design for the evaluation of community-based programs for vulnerable fathers. Although programs to increase and enhance father involvement exist in some communities, very few have been evaluated. The third study will develop a theoretical framework to assist in understanding and implementing programs and activities to promote responsible fathering. The last two projects are being conducted in collaboration with ACF.

Subacute Care--Market Analysis, Cost, and Quality

Subacute care is considered a cost-effective alternative to acute nursing home care services, that is, it can be provided in lower cost settings with no diminution of quality. ASPE has commissioned a study to identify and understand the definitions of subacute care; examine the provision of subacute care in select market areas by a variety of providers (e.g., hospital- based and freestanding skilled nursing facilities, rehabilitation and long-term care hospitals, and home health agencies); evaluate policy issues about who receives, provides, and pays for subacute care; and assess the cost, quality, and cost-effectiveness of this type of care.

Trends in the Well-being of America's Children and Youth

In fiscal 1995, ASPE provided funds for creating the first annual report on the health and well-being of America's children. The report will be a single volume that shows up-to-date trends on how our Nation's children are faring, pulling together information on all available national trends in the lives of children and youth. The volume will fill a crucial gap and will become an annual series to keep the Nation apprised of the well- being of its children and youth.

New Directions for ASPE Evaluation

Extensive new legislation, enacted during the current 104th Congress, will lead to the consideration of a range of new evaluations. First, understanding the effects of profound structural changes taking place in health care will be a majority priority for ASPE evaluation activity. The objective is to understand the changes on health status of families and individuals, access to quality health care, patterns of health care utilization and spending. Included is the need to evaluate the impact of Medical Savings Accounts on spending and savings and the connection between levels of income and amounts of savings under this option. A continuing and important evaluation objective is to support and promote the development and improvement of databases that ASPE and others can use to conduct evaluations of health care and human services programs and health and social trends.

Second, the welfare reform legislation also will require a varied evaluation response in order to assess the success of meeting the objectives of this legislation as well as to gather effective objective information on impacts on current and future recipients. It will also be critical to document and assess the impact of the recently enacted welfare legislation. The evaluation activities will focus on understanding the operation and organization of the new welfare system and assessing the impact of the changes on low-income families and children.

In other areas, ASPE will examine long-term initiatives that focus on the development and implementation of systems of acute care, subacute care, assisted living, long-term care, and personal assistance services for people with disabilities. ASPE will continue to develop effective indicators of the well-being of children in order to measure changes in the conditions of our children. ASPE will support the Departments' efforts to develop outcomes-based performance measures for health and social service programs, intended to provide the framework for new types of grant relationships with States.

Finally, one of ASPE's continuing and important evaluation objectives is to support and promote the development and improvement of databases that ASPE and others can use to conduct evaluations of health care and human services programs and health and social trends. All of the above activities will be supported with a combination of program appropriations, policy research, and evaluation funds.