Performance Improvement 1998. Office of the Assistant Secretary for Planning and Evaluation

02/01/1998

Contents

State Assisted Living Policy: 1996

Evaluation of the Minority Male Consortium for Violence Prevention

Determinants of AFDC Caseload Growth: Final Report

Informal and Formal Kinship Care

Approaches to Evaluating Welfare Reform: Lessons from Five State Demonstrations

Efforts by Child Welfare Agencies to Address Domestic Violence: The Experiences of Five Communities

Evaluability Assessment of Responsible Fatherhood Programs

Trends in the Well-Being of America's Children and Youth: '97

Assessment of Performance Measures for Public Health, Substance Abuse, and Mental Health

Registry of State-Level Efforts to Integrate Health Information

Implementing Welfare Reform Requirements for Teenage Parents: Lessons from Experience in Four States

Deriving State-Level Estimates from National Surveys: A Statistical Assessment and State Tabulations

Information Needs Associated with the Changing Organization and Delivery of Health Care: Summary of Perceptions, Activities, Key Gaps, and Priorities

Chapin Hall Center for Children at the University of Chicago: Administrative Data Guide

Iowa's Limited Benefit Plan

Role of Home- and Community-Based Services in Meeting the Health Care Needs of People with HIV/AIDS: Literature Review

Exploring the Feasibility of Linking Health Expenditure and Utilization Data

Public Health Laboratories and Health System Change

Framework for Assessing Insurer Responses to Health Care Market Changes

Establishing an Analytical Framework for Measuring the Role of Reinsurance in the Health Insurance Market

National Evaluation of Welfare-to-Work Strategies: Evaluating Two Welfare-to-Work Program Approaches: Two Year Findings on the Labor Force Attachment and Human Capital Development Programs in Three Sites

Improving Health in the Community: A Role for Performance Monitoring

Privacy and Health Research: A Report to the U.S. Secretary of Health and Human Services

State Regulatory Experience with Provider-Sponsored Organizations: Final Report

Indicators of Welfare Dependence and Well-Being: Interim Report to Congress

Setting the Baseline: A Report on State Welfare Waivers

Market Barriers to the Development of Pharmacotherapies for the Treatment of Cocaine Abuse and Addiction: Final Report

Consumer-Directed Personal Assistance Services: Key Operational Issues for State CD-PAS

Programs Using Intermediary Service Organizations

TITLE: State Assisted Living Policy: 1996

ABSTRACT: Assisted living facilities are an expanding source of supportive housing and services, and represent a new model of long-term care. Consumer choice and control are central to assisted living models, which seek to allow consumers to control key features of their living environments and to direct their own receipt of services. This study reviews the assisted living and board and care policies in each of the fifty States. Fifteen States have existing licensure regulations for assisted living facilities and an additional nine States are developing regulations. Twenty-two States reimburse or plan to reimburse assisted living as a Medicaid service and six States provide Medicaid payments for services in board and care settings. Thirteen states have created a task force or a process within a State agency to make recommendations for the development of assisted living rules. One of the major difficulties associated with assisted living is the lack of a common or standard definition of this kind of care. However, State approaches share common components, including that (1) assisted living is characterized as residential, rather than institutional; (2) health or medical services are provided, either by facility staff or through contracts with community agencies; (3) assisted living is a model emphasizing consumer or resident independence, autonomy, dignity, privacy, and decisionmaking; and (4) many States attempt to combine minimum standards of safety and quality of care while also allowing market forces to shape quality. State policies generally address three major issues: (1) the requirement for a living unit, (2) admission and retention criteria, and (3) the level of services to be provided. The report provides specific information about policies in each State. See also PIC ID Nos. 4719-4719.2 and 4719.4-4719.5. (Final report: 225 pages.)

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Robert Clark

PHONE NUMBER: (202) 690-6443

PIC ID: 4719.3

PERFORMER ORGANIZATION: Research Triangle Institute, Research Triangle Park, NC

TITLE: Evaluation of the Minority Male Consortium for Violence Prevention

ABSTRACT: This project evaluated the Office of Minority Health Minority Male Consortium for Family and Community Violence Prevention Programs. At the time of this study, 19 historically black colleges and universities (HBCUs) were participating in this program. Features of violence prevention program models at 13 historically black colleges and universities/family life centers (HBCUs/FLCs) were synthesized to determine approaches that could prevent or minimize violence in communities committed on or by minority males. The contractor (1) performed an extensive literature review; (2) collected and analyzed relevant program documentation and materials; (3) conducted focus groups; (4) examined target populations; (5) developed a site visit discussion guide; (6) selected 10 HBCUs for site visits; (6) developed and executed an analysis plan; (7) interpreted analysis findings, including defining program models and analyzing HBCUs' organizational capacity; (8) held briefings with Consortium leaders, members, and government personnel; (9) reviewed the overall organization, design, and implementation of the programs; and (10) evaluated prevention strategies adopted by the HBCU/FLCs. Violence prevention programs suffer from an inability to produce valid performance data demonstrating that prevention investments pay off in the long run. The report recommends that (1) without completely centralizing the design process, the Federal government and the Consortium should move toward a consensus-seeking information model in which individual schools are no longer free to pursue independent designs; and (2) constraints should be introduced on which program models are implemented by which schools. See also PIC ID Nos. 5789 and 5789.1. (Final report: 68 pages, plus appendices.)

AGENCY SPONSOR: Office of Program Systems

FEDERAL CONTACT: Patricia S. Hazard

PHONE NUMBER: (202) 690-8291

PIC ID: 5789.2

PERFORMER ORGANIZATION: Macro International, Incorporated, Calverton, MD

TITLE: Determinants of AFDC Caseload Growth: Final Report

ABSTRACT: This project examined the dynamics of Aid to Families with Dependent Children (AFDC) caseload growth and analyzed the effects of economic, demographic, and programmatic changes at the State level on States' AFDC caseload from the early 1980's to the present. Analysis of economic factors included measures of both wages and unemployment; analysis of demographic factors includes an emphasis on nonmarital childbearing. Analysis of program effects included changes arising from national welfare legislation, changes in State welfare parameters, State waivers, and changes in other programs such as Food Stamps and Medicaid. The project addressed the interaction of these factors by analyzing the economic, demographic, and programmatic factors simultaneously. Compared to earlier studies of AFDC caseload determinants, many of which are outdated, this study focused much more on State-level indicators, and included a more comprehensive set of economic, demographic, and programmatic factors. Recently, many State policymakers have expressed concern over the effect of future recessions or nonmarital birth rates on their caseloads, and this study is intended to be a valuable tool to State policymakers as they continue to assume greater responsibility for their AFDC programs and consider new innovations.

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Kelleen Kaye

PHONE NUMBER: (202) 401-6634

PIC ID: 5953

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Informal and Formal Kinship Care

ABSTRACT: A growing number of States prefer to place children who have been removed from their homes of origin in the home of a relative. This practice is known as kinship foster care, and is a growing component of family foster care. It comprises between one-third and one-half of all foster care days provided in the States with the largest foster care populations. Many children, however, live with relatives who are not their parents in an informal relationship. In all, about 2.15 million children lived in the care of relatives without a parent present in 1994. This study uses several data sources to examine the characteristics of informal kinship care arrangements and how they compare with those initiated through or subsidized by the State child welfare system. It considers national patterns, examines living arrangement patterns by State for FY 1990, compares formal and informal kinship care in four States, and uses Illinois data to provide a more focused picture of kinship care. The two-volume report finds that (1) kinship care is more prevalent in the South and in non-metropolitan areas, and for older children; (2) about two-thirds of kinship caregivers are the child's grandparents-about half are currently married, and over 85 percent of single kinship caregivers are women; (3) kinship caregivers are more likely to be currently unmarried, to be less educated, to be poor, and to receive social welfare benefits than are live-in parents; (4) nationally, just over 2 percent of children lived with relatives not their parents (this percentage ranges by State from under 1 percent to well over 3 percent) (5) higher levels of kinship care (as well as single mother households) appear to be direct products of higher levels of social disruption and family disorganization; and (6) while informal kinship care patterns were roughly similar in the four States examined, the use of formal kinship care varies widely. (Vol. I: 80 pages; Vol. II-tables and figures-58 pages plus appendices.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Laura Feig

PHONE NUMBER: (202) 690-5938

PIC ID: 6016

PERFORMER ORGANIZATION: University of Chicago, Chicago, IL; Urban Institute, Washington, DC

TITLE: Approaches to Evaluating Welfare Reform: Lessons from Five State Demonstrations

ABSTRACT: Most States have obtained waivers from Aid to Families with Dependent Children (AFDC) and Food Stamp Program rules in order to implement welfare reform. Between 1993 and 1996, the Clinton Administration approved waivers for 43 States. This project examined waiver demonstration projects in five States (California, Colorado, Michigan, Minnesota, and Wisconsin). Four of the five States used an experimental evaluation design, while the fifth used a quasi-experimental evaluation design. This two-volume report addresses issues in five areas: (1) the choice between an experimental and quasi-experimental evaluation design, (2) sample design, (3) implementation of experimental evaluations, (4) data collection, and (5) analysis methods. The report finds that: (1) most evaluations of State welfare reform demonstrations used an experimental design, which involved random assignment of cases to an experimental group subject to welfare reform or to a control group subject to pre-reform policies; (2) only one waiver (Wisconsin's) was approved with a quasi-experimental design, but this may become more common in a block grant environment; and (3) when designing a study sample, evaluation planners should ensure that the sample size is adequate and should design the sample so that applicant and recipient subgroups can support separate impact estimates (the sample should also be representative of the State as a whole). The report also finds that four aspects of the implementation of an experimental evaluation require special care: (1) the timing of the random assignment, (2) the method of the random assignment, (3) ensuring that control group policies remain unchanged, and (4) preventing experimental and control group cases from changing status. The report also discusses data collection and analysis. (Final report: Volume I: 128 pages, plus appendices; Volume II: 8 pages.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Audrey Mirsky-Ashby

PHONE NUMBER: (202) 401-6640

PIC ID: 6050

PERFORMER ORGANIZATION: Urban Institute, Washington, DC

TITLE: Efforts by Child Welfare Agencies to Address Domestic Violence: The Experiences of Five Communities

ABSTRACT: Child protective services (CPS) and domestic violence services historically have not been closely linked. However, child welfare agencies across the country are beginning to consider how families in their child protection caseload are affected by domestic violence and are reexamining their policies accordingly. This report documents how child welfare agencies in five communities (Massachusetts; Michigan; San Diego County, California; Hilo, Hawaii; and Oregon) are attempting to integrate domestic violence concerns into their services. The communities were chosen for study because they are extending their services well beyond educating staff in domestic violence concerns. The report finds that (1) child welfare agencies have initiated changes from different organizational points within their agencies and have taken different approaches to changing case practice; (2) these agencies cannot make appropriate changes without major and continuing collaboration with community stakeholders who work with domestic violence victims and perpetrators; (3) chief among the concerns raised is the need to refrain from actions that further endanger mothers and children; (4) changes will also benefit from close collaboration with police, civil and criminal courts, corrections, the schools, and local clinics and hospitals; and (5) ongoing technical assistance to CPS staff after initial training in domestic violence services appears to make a more lasting difference on workers' ability to put the content of training into practice on a daily basis. The report closes with a general discussion of (1) approaches to addressing domestic violence within child welfare agencies; (2) the role of the larger community; (3) more complex policy questions, such as whether a child's witnessing of domestic violence is itself abusive; and (4) evaluating the effectiveness of these efforts. (Final report: 148 pages.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Jerry Silverman

PHONE NUMBER: (202) 690-5654

PIC ID: 6155

PERFORMER ORGANIZATION: Urban Institute, Washington, DC

TITLE: Evaluability Assessment of Responsible Fatherhood Programs

ABSTRACT: Responsible fatherhood programs provide fathers, particularly those who are young, unmarried, and unemployed, with the support and skills to become active participants in their children's lives. An increased interest in fatherhood programs and a lack of information on their accessibility and effectiveness led to this evaluability assessment. This study visited five fatherhood program sites, selected as the most developed programs by HHS, in order to (1) assess the readiness of fatherhood programs for formal evaluation and identify obstacles to their evaluation in the future, and (2) illustrate the evaluation process and mechanisms that must be in place before a formal impact evaluation is undertaken. The project goal was to develop an evaluation design that could be used by HHS and other policymakers in the future to evaluate such programs. The report concludes that at this time formal program evaluation remains premature because the programs (1) are new and still at the stage of refining recruiting methods and program services, (2) lack automated systems for tracking and reporting on clients, and (3) serve a very small number of clients. In order to conduct a rigorous evaluation of fatherhood programs, the report suggests the development of (1) measurable outcomes; (2) defined service components and their hypothesized relationship to outcomes; (3) an established recruiting, enrollment, and participation process; (4) an understanding of the characteristics of the target population, program participants, and program environment; and (5) an ability to collect and maintain an adequate program size. The report concludes that to increase viability, fatherhood programs must (1) develop a core definition of what constitutes a responsible fatherhood program, (2) conduct process evaluations, (3) build basic management information system capacity, and (4) stabilize and enhance funding. (Final report: 114 pages, plus appendices.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Linda Mellgren

PHONE NUMBER: (202) 690-6806

PIC ID: 6159

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Trends in the Well-Being of America's Children and Youth: '97

ABSTRACT: This is the second edition of an annual report from HHS on the well-being of children and youth in the United States. The report's purpose is to provide the policy community, the media, and all interested citizens with a statistical overview describing the condition of children. The report focuses on trends in the well-being of children and youth in five key areas: population, family, and neighborhood; economic security; health conditions and health care; social development, behavioral health, and teen fertility; and education and achievement. The report, as it pertains to teenagers, finds (1) a decrease in the pregnancy rate among young women aged 15-19 since 1991; (2) an increase in alcohol, cigarette, marijuana, and cocaine use in the 1990's; (3) a modest gain in math and science proficiency by 17-year-old students since the early 1980's; (4) a sustained increase in mortality for black youth aged 15-19 since 1991, while there was a decrease in mortality rates for white youth; and (5) a steady increase in receipt of early prenatal care by teen mothers. Federal statistical data lack (1) standardized measures of social development and health-related behaviors for very young and pre-teenaged children; (2) indicators that reflect important social processes affecting child well-being that go on inside the family and within the neighborhood; and (3) sufficient information on child abuse and neglect, youth violent crime, day care quality, learning disabilities, and measures of children in institutionalized care. The Federal Interagency Forum on Child and Family Statistics has adopted a mandate to improve the statistical system. As data become available they will be incorporated into new editions of this report. (Final report: variously paginated.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Matthew Stagner

PHONE NUMBER: (202) 690-5653

PIC ID: 6170.1

PERFORMER ORGANIZATION: Urban Institute and Child Trends, Incorporated, Washington, DC

TITLE: Assessment of Performance Measures for Public Health, Substance Abuse, and Mental Health

ABSTRACT: The Panel on Performance Measures and Data for Public Health Performance Partnership Grants (PPGs) was established in order to examine the state-of-the-art in performance measurement for public health and to recommend measures that could be used to monitor the PPG agreements to be negotiated between each State and the Federal government. The panel considered performance measures in ten public health areas: chronic diseases, sexually transmitted diseases, human immunodeficiency virus infection and tuberculosis, mental health, immunization, substance abuse, sexual assault, disabilities, and emergency medical services. More than 3,200 measures were proposed to the panel through various outreach efforts. The panel used four guidelines for assessing the performance measures: (1) the measure should be specific and results oriented; (2) the measure should be meaningful and understandable; (3) data should be adequate to support the measure; and (4) the measure should be valid, reliable, and responsive. The measures that scored the highest are recommended for use in performance monitoring. They cover health status, social functioning, consumer satisfaction, and risk status. In assessing the adequacy of data for specific performance measures, the panel concluded that there are few available data sources that are ideal for performance monitoring. Many Federal efforts to collect health-related data provide national rates, but do not collect data that provide State-level rates, and much State-level data may not be comparable. The report also finds that many of the performance measures presented can and should be subdivided to focus on specific high-risk populations in a State. See also PIC ID No. 6200. (Final report: 54 pages, plus appendices.)

AGENCY SPONSOR: Office of Program Systems

FEDERAL CONTACT: Jeffery J. Koshel

PHONE NUMBER: (202) 401-8238

PIC ID: 6177

PERFORMER ORGANIZATION: National Academy of Sciences, Institute of Medicine, Washington, DC

TITLE: Registry of State-Level Efforts to Integrate Health Information

ABSTRACT: In 1996, HHS contracted The Lewin Group to develop a registry of projects that integrates health information systems at the State level. The registry is located on the World Wide Web at

http://aspe.hhs.gov/statereg/index.htm. The home page compiles, abstracts, and indexes summary information on data integration projects for all 50 States and the District of Columbia. The purpose of the registry is twofold. First, the registry gives Federal policymakers a central source for researching the types of integration activities being pursued by individual States. Second, the registry facilitates communication among States regarding data integration activities and related data policy activities. The project (1) provides a resource for State and local policymakers as they seek to identify others who have pursued information integration activities; (2) facilitates information sharing and collaboration across States; and (3) assists Federal policymakers in monitoring, assessing, and supporting State-level integration activities. Relevant State integration projects were identified through: (1) contacts with State officials responsible for hospital discharge data bases, vital statistics, Medicaid data, and any other major information system or data-related offices; (2) conferences on State data integration activities; (3) grantee information related to specific funds which target information activity; (4) State health department websites; and (5) recommendations from people interviewed. A contract with The Lewin Group has been issued to organize and edit the materials that are submitted and encourage biannual updates of the site. The data base is administered by the Office of the Assistant Secretary for Planning and Evaluation. Final report is a web site: http://aspe.hhs.gov/statereg/index.htm.

AGENCY SPONSOR: Office of Program Systems

FEDERAL CONTACT: Dale Hitchcock

PHONE NUMBER: (202) 690-5882

PIC ID: 6178

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Implementing Welfare Reform Requirements for Teenage Parents: Lessons from Experience in Four States

ABSTRACT: Federal welfare policy requires minor custodial parents receiving cash assistance to attend school and to live with their parents or in an adult-supervised setting; these requirements were established as part of the Personal Responsibility and Work Opportunity Reconciliation Act, which created the program for Temporary Assistance for Needy Families and abolished the Aid to Families with Dependent Children (AFDC) program. This two-volume report summarizes lessons learned from the operational experiences in four States (Arizona, California, Massachusetts, and Virginia) that implemented waivers requiring school attendance and certain living arrangements under the AFDC program. The report finds that (1) identifying teenage parents, particularly those who do not head their own cash assistance cases, can be a major challenge; (2) persistent staff training to correct errors, the use of alternative information sources to identify teenage parents, and establishing positive incentives for identifying and referring all teenage parents can help to address these challenges; (3) a range of education options, including GED programs, should be available; (4) programs must determine the focus and scope of case management in light of goals and costs; (5) monitoring school attendance increases welfare agency workload-sometimes substantially-and can complicate the relationship between welfare agencies and schools; (6) a very restrictive living arrangement requirement may create implementation difficulties; and (7) funding group homes may enable States to have fewer exceptions to the requirement, but despite their advantage for teen parents, many may not choose to reside in them. (Final report: Volume I, 50 pages; Volume II (case studies), 103 pages.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Kelleen Kaye

PHONE NUMBER: (202) 401-6634

PIC ID: 6228

PERFORMER ORGANIZATION: Mathematica Policy Research, Incorporated, Plainsboro, NJ

TITLE: Deriving State-Level Estimates from National Surveys: A Statistical Assessment and State Tabulations

ABSTRACT: The Department of Health and Human Services (HHS) is changing its focus from the national to the State level. Landmark legislation eliminating entitlement to Aid to Families with Dependent Children benefits and block granting it to the States was passed at the time of this report. This project is one component of a larger HHS strategy to generate valid and reliable State-level estimates, which can be used to measure the impact of social policy interventions. This project (1) appreciates the statistical issues involved in addressing policy and research questions at the State level with national survey data; (2) assesses the current capabilities of these major surveys to provide answers to these questions at the State level; and (3) presents options for obtaining valid, reliable State-level data from relatively minimal enhancements and changes to the design of the surveys. The study focused on three major Federal surveys: the Survey of Income and Program Participation (SIPP); the Current Population Survey (CPS); and the National Health Interview Survey (NHIS). These surveys were selected for their widespread applicability, use, and potential for analyzing policy issues. The report evaluates statistical concerns to determine the suitability and potential of using the selected surveys for State-level estimates and to identify differences between States. These technical concerns included variance estimation, standard errors, the construction of State-level weights, minimum sample sizes needed, design effects, pooling several years of data, and longitudinal issues (e.g., response rates and weighting). The report recommends periodic redesign efforts and other survey enhancements.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: George Greenberg

PHONE NUMBER: (202) 690-7794

PIC ID: 6380

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Information Needs Associated with the Changing Organization and Delivery of Health Care: Summary of Perceptions, Activities, Key Gaps, and Priorities

ABSTRACT: This report assesses unmet needs for supply-side information (information about health care providers and insurers) on the health system, focusing on helping the Department of Health and Human Services identify how information needs associated with a changing health care system are perceived by a wide variety of user groups and constituencies. Based on information gathered from over 50 individuals and a review of relevant literature and Web sites, the report examines perceived gaps, their causes, and the activities generated in response to those perceptions. It also considers, in a more comprehensive manner, information on a diverse group of 11 entities. The report finds that (1) the serious gaps in "supply-side" information on the health system have grown worse as the system has evolved, presenting major obstacles to stakeholders' ability to serve their constituency, address operational needs, and participate in policy decisions; (2) the growth of managed care and consolidation has contributed to the need for supply-side information, as has the growing interest in accountability, competition, and cost-containment; (3) stakeholders say they need better information on health insurers and plans and the ways in which providers are linked to plans and integrated systems; and (4) better transaction-level data are needed, as are data from the State and local levels. The report identifies 23 ongoing efforts within the private sector, States, and foundations to address these gaps, and studies 11 of these more thoroughly. The report concludes that private sector stakeholders and States alone cannot sufficiently address supply-side information needs, giving importance to Federal leadership and convening functions. (Final report: 61 pages, plus appendices.)

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Linda Sanches

PHONE NUMBER: (202) 690-7233

PIC ID: 6388

PERFORMER ORGANIZATION: Mathematica Policy Research, Incorporated, Plainsboro, NJ

TITLE: Chapin Hall Center for Children at the University of Chicago: Administrative Data Guide

ABSTRACT: This contract produced a guide to the administrative data resources regarding health, social services, and related programs available through the Chapin Hall Center for Children at the University of Chicago. Each data section in the guide provides an overview of a particular dataset. The sections offer enough information for the researcher to gain a general understanding of the available variables and the types of analysis the data will support. Data Description and Limitation entries document the larger issues involved with analyses of the data and should not be considered exhaustive. The guide also includes information to assist the researcher in interpreting the data sections. The guide was designed for use by an audience of informed policy analysts in order to consider what data are available to answer particular policy questions. It is not intended that the guide be a detailed programmer's reference book to every code used in each data field, but rather that it describe the data sets available, the basic structure and topics covered by each, and the ability to match clients between the different programs' data. The goal of this guide is to enable the Office of the Assistant Secretary for Planning and Evaluation's policy and research analysts to better design relatively short-turnaround analyses on a variety of topics of current policy interest. The guide may also be useful to other researchers. (Final report: 110 pages, plus appendices.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Laura Feig

PHONE NUMBER: (202) 690-5938

PIC ID: 6389

PERFORMER ORGANIZATION: Chapin Hall Center for Children, University of Chicago, Chicago, IL

TITLE: Iowa's Limited Benefit Plan

ABSTRACT: Iowa's Family Investment Program (FIP) replaced Aid to Families with Dependent Children in 1993. FIP participants who are able-bodied and not caring for children, yet who do not develop and carry out a Family Investment Agreement (FIA), are sanctioned with assignment to the Limited Benefit Plan (LBP); some clients may also choose LBP over FIP. LBP originally provided 3 months of benefits at FIP levels, followed by 3 months of reduced levels and 6 months of no cash benefits; the program was later changed to eliminate the original 3-month period. At the end of the 6-month period, the client can reapply for FIP, but must meet its requirements. This report present finding from a study of the original LBP, showing how some families enter the LBP and how their well-being changes after benefits are cut. It examines records for over 4,200 cases assigned to LBP records during 6 months in 1994 and 1995, a survey of 137 cases whose cash benefits were terminated, and case studies of 12 LBP families. The report finds that (1) most clients are assigned to LBP for failing to develop and sign an FIA, rather than for failing to carry it out; (2) slightly more than half of LBP clients subsequently meet FIP requirements and are reassigned to the program; (3) about half of LBP clients whose cash benefits have been terminated are employed immediately after cash benefits end, but about half are not; (4) 40 percent of these clients increase their monthly incomes by an average of $496 when their benefits end, but 47 percent see a decrease in their monthly incomes averaging $384; and (5) other government programs remain important sources of support for LBP families whose cash benefits have been terminated. The report notes that there are several features of the LBP program that mitigate against extreme deprivation when cash assistance has been terminated, and notes that the absence of these safeguards in a national welfare reform program could result in extreme hardship for many families. (Final report: 132 pages plus appendix.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Kelleen Kaye

PHONE NUMBER: (202) 401-6634

PIC ID: 6390

PERFORMER ORGANIZATION: Mathematica Policy Research, Incorporated, Washington, DC

TITLE: Role of Home- and Community-Based Services in Meeting the Health Care Needs of People with HIV/AIDS: Literature Review

ABSTRACT: This report provides an overview of the literature describing the delivery and financing of home- and community-based services for people with AIDS, focusing on the literature published since 1991. The literature review finds that (1) since the start of the epidemic, the AIDS population has been decreasingly made up of white male homosexuals and increasingly made up of people of color with low incomes and low educational levels; (2) new AIDS treatments combining protease inhibitors and other antiretroviral medications may increase life expectancy among some people with AIDS but annual costs range from $9,000 to $18,000 per person; (3) the lifetime cost of AIDS treatment has been rising, since drugs have been increasing life expectancy even before the introduction of protease inhibitors; (4) AIDS patients who experience periods of disability require nursing and support services to complement medical care, including assistance with daily living activities, child care, transportation, help applying for public assistance, and the like; (5) the increasing number of low-income people with AIDS places a heavier burden on public programs such as Medicaid and Ryan White CARE Act funding; (6) the Medicare program has borne a relatively small proportion of the burden for AIDS care, but this may increase as life expectancy increases; (7) rigorous evaluation of programs that provide home- and community-based services to people with AIDS appears to be lacking; (8) the literature provided little data describing current levels of use of and cost for home- and community-based services by people with AIDS; and (9) there is little information about how effectively managed care is meeting the need for these services. The review examines literature on the provision of these services to these elderly to draw inferences for their application to the AIDS population. See also PIC ID No. 6418. (Final report: 92 pages.)

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Gavin Kennedy

PHONE NUMBER: (202) 690-6443

PIC ID: 6418.1

PERFORMER ORGANIZATION: Mathematica Policy Research, Incorporated, Plainsboro, NJ

TITLE: Exploring the Feasibility of Linking Health Expenditure and Utilization Data

ABSTRACT: The Health Resources and Services Administration (HRSA) has the responsibility for assessing the adequacy of the Nation's supply of various health professions. HRSA commissioned a "General Services Demand Model" (GSDM) in 1994 to permit State-specific estimates of health utilization, which it then inputs into State-specific provider requirements forecasts. HRSA's GSDM predicts, for each State and the District of Columbia: bed days in short-term general hospitals for the under-65 and over-65 populations, outpatient visits, and emergency visits. HRSA then takes these predictions and estimates requirements for various health professions for each State. The estimates are typically based on assumptions about appropriate provider staffing/utilization ratios; for example, each primary care physician can perform 3,000 office visits in a year. From the data and assumptions, a set of State-specific provider requirement forecasts can be generated. In general, these forecast supply and demand for physicians by speciality type, as well as for registered nurses. The Health Care Financing Administration compiles national health account expenditures for hospital services, physician services, prescription drugs, and other areas. The goal of these projects is to link these two data bases over a 2 to 3-year period and then use the model to simulate the utilization and cost savings potential of reorganizing the delivery of care (for example, using HMO specialist/generalist staffing ratios versus the current fee-for-service norms). The ultimate model could be used to analyze utilization and expenditure patterns. We know, for example, that managed care enrollees, other things being equal, have 20 percent fewer beds and 10 percent fewer specialist visits than indemnity enrollees. The ultimate model could provide an estimate of utilization and cost-savings effects of HMOs entering and achieving a 30 percent share in, for example, Alabama over the next 5 years.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: George Greenberg

PHONE NUMBER: (202) 690-7794 or 690-7804

PIC ID: 6425

PERFORMER ORGANIZATION: Urban Institute, Washington, DC

TITLE: Public Health Laboratories and Health System Change

ABSTRACT: All 50 States and the District of Columbia operate their own Public Health Laboratories (PHLs). Changes in the private health care delivery system, especially the growth of managed care organizations (MCOs), hospital consolidations, and large commercial laboratories are causing public health professionals to examine the viability of publicly funded laboratories in this new environment. The study identifies aspects of the public health infrastructure critical for developing assessment and evaluation tools. The report includes a literature review, interviews with stakeholders, an informal poll of State PHL directors, and detailed case studies of three States that have PHLs with relationships with MCOs and/or private laboratories. The report concludes that (1) PHLs are part of the broader public health infrastructure and, as such, must respond to changes in the health care marketplace; (2) services that are not commercially viable within the private sector, and those that are critical to identifying emerging diseases, should remain in the domain of PHLs; (3) assurance of quality and consistency of laboratory testing are critical functions of PHLs; and (4) policy development in laboratories needs to address the growth of managed care and changes in the health care delivery system. The study recommends increased Federal guidance in (1) assessing the regionalization of laboratory services, (2) supporting information infrastructure development, and (3) facilitating communication between private and public sectors. (Final report: variously paginated.)

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Cheryl Austein Casnoff

PHONE NUMBER: (202) 690-6102

PIC ID: 6458

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: A Framework for Assessing Insurer Responses to Health Care Market Changes

ABSTRACT: Over the past 15 to 20 years, the health insurance market has changed dramatically. Where once a few large commercial carriers dominated the market with fee-for-service plans, there are now dozens of plans in most markets. In highly competitive markets, plans and carriers develop more sophisticated strategies and arrangements to identify and retain target markets. In order to successfully integrate government programs and develop public policy, insurers' business strategies need to be better understood. Understanding insurers' strategies is important for policy analysis because insurers are often regulated entities; and insurers' responses to changing market and regulatory conditions affect both patients' and providers' opportunities and outcomes. This report (1) identifies insurer and insurance market characteristics that are likely to be important determinants of insurers' response to policy changes (such as insurance market reform) and changes in local market conditions (such as aggressive entry of managed care plans), (2) identifies potential data sources and data needs for future empirical work, and (3) provides a better understanding of the operation of insurance markets and how insurers make business decisions based on the demand for insurance from employers and individuals. In order to improve the analysis of health insurance markets, the report recommends (1) measuring changes in the relative density of the health plan contour "web," (2) tracking premiums and loading factors, (3) monitoring the self-insured market, and (4) watching organized buyers. (Final report: 44 pages.)

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Stephen Finan

PHONE NUMBER: (202) 690-7387

PIC ID: 6572

PERFORMER ORGANIZATION: Urban Institute, Washington, DC

TITLE: Establishing an Analytical Framework for Measuring the Role of Reinsurance in the Health Insurance Market

ABSTRACT: Reinsurance is widely used by underwriters of health benefits to limit their risk exposure. Reinsurance contracts can be structured in many ways, and insurers can use it to limit their risk for an individual contract or exposure, for a group of contracts or exposures, or for a whole portion of the insurer's business. This report presents a limited analytical study of the level of risk borne by reinsurers in three markets: the indemnity insurance market, the managed care market, and the self-insured employer benefit plan market. The study focuses on three States using public and private data sources, including surveys, published private data, and information from filings made by private insurance companies. The purpose of the study is to determine to what extent these data can be used to measure the role of reinsurance in the various markets and to suggest ways whereby better assessments of reinsurance might be made. The report was generally unable to identify either data sources or existing research allowing quantification of the risk being ceded to reinsurers in the three markets. While a substantial amount of information is available about reinsurance in indemnity (non-HMO) health insurers, the data are aggregated in ways that make it difficult to specifically identify transactions related to primary health insurance offered to groups and individuals. Information from State HMO insurance filings is more useful, but lack of detail and inconsistencies in the way that HMOs report the information in their annual statements reduces its analytic potential. Finally, despite the substantial amount of information available about the prevalence of self-funding and the use of reinsurance by self-funded employers, there are virtually no reliable data about the level of risk being transferred to reinsurers in these arrangements. The report closes with suggestions for enhancing the data available on this subject. (Final report: 23 pages, plus appendices.)

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Stephen Finan

PHONE NUMBER: (202) 690-7387

PIC ID: 6573

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: National Evaluation of Welfare-to-Work Strategies: Evaluating Two Welfare-to-Work Program Approaches: Two Year Findings on the Labor Force Attachment and Human Capital Development Programs in Three Sites

ABSTRACT: This report is part of a larger study called the National Evaluation of Welfare-to-Work Strategies, formerly known as the JOBS Evaluation, which has randomly assigned more than 55,000 individuals in seven sites to groups eligible for specific welfare-to-work programs and to control groups that do not participate in these programs. This study compares two distinct welfare-to-work strategies-labor force attachment (LFA) and human capital development (HCD)-at each of three of sites: Atlanta, GA; Grand Rapids, MI; and Riverside, CA. At each site, Aid to Families with Dependent Children applicants were randomly assigned to one of three groups: a group subject to the LFA program, a group subject to the HCD program, or a control group not subject to any welfare-to-work program. This report presents findings on the implementation, participation patterns, and costs of the two types of programs operated at each site. Additionally, the report assesses the two program approaches in promoting employment and reducing welfare expenditures after 2 years. The study finds that (1) the LFA programs increased participation in the job search and HCD programs increased participation in adult basic education; (2) welfare sanction rates for nonparticipation were higher in the LFA and HCD programs than in previously studied programs, although higher sanction rates were not associated with higher rates of eventually participating in program activities; (3) the HCD programs cost about twice as much as the LFA programs; (4) both programs increased individuals' 2-year cumulative employment and earnings, and (5) both programs reduced welfare expenditures within the 2-year followup period. The report concludes that a period of 2 years is insufficient to make a credible comparison of the two approaches. See also PIC ID series 5776 and PIC ID Nos. 6576 and 6576.2. (Executive summary: 36 pages; final report: 276 pages, plus appendices.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Audrey Mirsky-Ashby

PHONE NUMBER: (202) 401-6640

PIC ID: 6576.1

PERFORMER ORGANIZATION: Manpower Demonstration Research Corporation, New York, NY

TITLE: Improving Health in the Community: A Role for Performance Monitoring

ABSTRACT: This report draws on lessons from a number of current community health efforts to outline the elements of a community health improvement process, discusses the role that performance monitoring can play in this process, and proposes tools to help communities develop performance indicators. A recent emphasis on the interdependence of stakeholders requires collaborative efforts to improve community health: performance monitoring (a continuing process of selecting indicators that can be used to measure the process and outcomes of an intervention and making the results available to the community) has gained increasing currency as a way to do so. The report finds that a community health improvement process (CHIP) can be an important tool for developing a shared vision and supporting a planned and integrated approach to improving community health. The report suggests that a CHIP should include two principal interacting cycles based on analysis, action, and measurement: (1) a problem identification and prioritization cycle; and (2) the analysis and implementation cycle. This system differs from standard models primarily because of its emphasis on measurement to link performance and accountability on a community-wide basis. The report offers recommendations for implementing the CHIP concept: (1) communities should base a health improvement process on a broad definition of health and a comprehensive conceptual model of how health is produced within the community; (2) a CHIP should develop its own set of specific, quantitative performance measures and should seek a balance between strategic opportunities for long-term health improvement and short-term goals; (3) State and local health agencies should assure that an effective community health improvement process is in place in all communities; and (4) the Public Health Service should provide support and guidance in these efforts. (Final report: 179 pages, plus appendices.)

AGENCY SPONSOR: Office of Program Systems

FEDERAL CONTACT: James Scanlon

PHONE NUMBER: (202) 690-7100

PIC ID: 6583

PERFORMER ORGANIZATION: National Academy of Sciences, Institute of Medicine, Washington, DC

TITLE: Privacy and Health Research: A Report to the U.S. Secretary of Health and Human Services

ABSTRACT: This report (1) identifies privacy issues surrounding research on personally identifiable health data, paying special attention to the international aspects; (2) reviews the ethical, legal, and general social context surrounding the privacy and confidentiality of health data; (3) describes relevant privacy-protection practices and problems, and identifies emerging issues; (4) analyzes the implications of the new European Union Data Privacy Directive and related policy and legal changes; and (5) recommends policy approaches and technical processes for ensuring that the privacy of individuals is respected. The report examines four major groups of issues that are growing rapidly in scale and complexity, and that must be urgently attended to: (1) secondary uses of data and data linking, (2) research on private-sector health data, (3) cybersecurity, and (4) genetic privacy. The report finds that (1) as data bases are maturing and increasing in size and quality, their appeal as research resources is also growing; (2) if personally identifiable data must be used in secondary research, consent will become the most difficult issue; (3) for many health data held in the private sector, few legal controls apply in theory or are enforced in practice regarding such matters as data-subject consent, public notification, or transfer of the data for secondary study; (4) protection of the confidentiality and security of health data, especially electronic data, is being reviewed worldwide; and (5) developing ethical guidance over genetic privacy is crucial to the future of both genetic research and applied genetics. The report also examines the international flow of data, new health data privacy laws in Europe, the United States' new "Health Insurance Portability and Accountability Act," and the need for dialogue between the United States and Europe. (Final report: 76 pages plus appendix.)

AGENCY SPONSOR: Office of Program Systems

FEDERAL CONTACT: John Fanning

PHONE NUMBER: (202) 690-7100

PIC ID: 6605

PERFORMER ORGANIZATION: William W. Lowrance, Ph.D., Geneva, Switzerland

TITLE: State Regulatory Experience with Provider-Sponsored Organizations: Final Report

ABSTRACT: This report describes the experience of selected State governments in regulating provider-owned health care delivery systems that accept insurance risk for the provision or arrangement of health care services (provider-sponsored organizations, or PSOs). The States included in the study are California, Colorado, Illinois, Iowa, Minnesota, Ohio, Pennsylvania, Texas, and Washington. The report finds that the main models States use to regulate the activities of PSOs contracting directly with purchasers of health care (e.g., employers) are (1) licensing these organizations as they would a non-provider owned entity, and (2) creating a separate licensing category for risk-assuming PSOs. Regulators in States using the first model regulate the activity of risk assumption; in some cases, they apply regulation pertaining to non-provider managed care entities to all organizations seeking to seeking to provide or arrange for health care delivery. In States where PSOs are licensed separately from other managed care organizations, differences in the standards required for PSOs varied and there was little consistency about the rationale for having separate licensing. The report also finds that the States vary considerably in their regulation of PSOs that assume risk from self-funded, ERISA-exempt employer plans. Most consider the PSO as engaging in the business of insurance (thus they may be regulated by the State despite the plan's ERISA status). States also vary in their regulation of PSOs that accept risk downstream from licensed insurance carriers or managed care organizations: some do not regulate these relationships, while others require special licensing or impose substantial requirements governing risk transfer agreements. The report concludes that, since State policy toward PSOs is still in the early stages of development, the lessons to be drawn for Federal policymakers is limited; however, some observations are offered.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Lisa Rovin

PHONE NUMBER: (202) 690-7800

PIC ID: 6628

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Indicators of Welfare Dependence and Well-Being: Interim Report to Congress

ABSTRACT: The Welfare Indicators Act of 1994 directed the Secretary of Health and Human Services to conduct a study to determine which statistics would be most useful in tracking and predicting dependence on three means-tested cash- and nutritional-assistance programs: Aid to Families with Dependent Children, Food Stamps, and Supplemental Security Income. Enactment of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 makes this task even more important. As this bill is implemented, traditional indicators of dependence may lose their meaning, making dependence more difficult to track over time. In response to these difficulties, this report recommends indicators that measure family well-being in addition to those that measure dependence. The report recommends two kinds of indicators: indicators of dependence, self-sufficiency, and family conditions; and indicators of child achievement, health, and well-being. In most cases, the recommended indicators should be tabulated separately for children, male non-elderly adults, female non-elderly adults, and other important population subgroups wherever possible. To measure dependence, self-sufficiency, and family conditions, the report recommends that indicators reflect points on a continuum from total dependence to complete self-sufficiency. Recommended indicators are grouped into several categories, including: (1) range of dependency, (2) work and job readiness, (3) poverty and deprivation, (4) family structure, and (5) parenting. To measure child achievement and health, the report recommends using indicators of infant and child mortality, low birthweight, child health limitations, teen birth rates, teen violent crime arrests, and others. Finally, the report discusses data needs for the recommended indicators. (Final report: variously paginated, plus appendices.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Susan Hauan

PHONE NUMBER: (202) 690-8698

PIC ID: 6634

PERFORMER ORGANIZATION: Office of the Assistant Secretary for Planning and Evaluation, Washington, DC

TITLE: Setting the Baseline: A Report on State Welfare Waivers

ABSTRACT: The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 eliminated the entitlement to Aid to Families with Dependent Children (AFDC) and replaced it with Temporary Assistance for Needy Families (TANF), a block grant which States can use to provide cash and services to low-income families with children. This report is one in a series designed to provide baseline information on the AFDC program as it existed prior to enactment of the new law. The report focuses on the waivers of AFDC requirements that were granted to States in the years preceding enactment of PRWORA. Between 1993 and 1996, waivers were granted to 43 States to help them reform their welfare programs. The report provides an overview of the types of waivers that States requested and received, and provides details on specific State policies. The report finds that, in many regards, the waiver programs were the first phase of welfare reform. States were required to conduct evaluations of waiver impacts, and had to ensure that the programs would be cost-neutral (that is, that they would not require additional Federal spending). This cost-neutrality could be achieved over the entire waiver period, rather than in each year, as had been previously required. This allowed States to make large up-front investments that they expected to gain back through reduced benefit payments in later years. The report provides valuable information about how specific States approached the AFDC program and what the Federal government authorized them to implement so that the effects of the TANF program can be measured State by State. Furthermore, the TANF program allows States to maintain their waiver programs or to delay implementation of certain TANF provisions until their waiver expires. The bulk of the report consists of tables presenting information on various aspects of the waiver programs. (Final report variously paginated.)

AGENCY SPONSOR: Office of Human Services Policy

FEDERAL CONTACT: Elizabeth Lower-Basch

PHONE NUMBER: (202) 690-6808

PIC ID: 6651

PERFORMER ORGANIZATION: Office of the Assistant Secretary for Planning and Evaluation, Washington, DC

TITLE: Market Barriers to the Development of Pharmacotherapies for the Treatment of Cocaine Abuse and Addiction: Final Report

ABSTRACT: This report presents an analysis of the market barriers to development of pharmacotherapies for substance abuse and addiction, particularly for abuse of and addiction to cocaine. There are more than 2 million addicted or "heavy" cocaine users. Of these, almost a million may enter treatment at least once in a given year. On any given day, about 10 percent of heavy cocaine users are enrolled in treatment programs. The report examines the development of pharmacotherapies for cocaine abusers in the light of the size of the potential market, estimates of market penetration, and the basic relationships between price, market size, and revenues. The report finds that there are several critical market barriers that must be taken into account. For example, there is a small and uncertain market for cocaine addiction and abuse pharmacotherapy. Although drug companies agree that the total number of cocaine users is significant, they believe that the feasible market for a cocaine abuse treatment is likely to be much smaller than the absolute number of people who use cocaine. Drug companies also anticipate that market penetration would be uncertain; potential patient compliance problems, limited access to patients, and the fact that most substance abuse treatment providers view drug use as a behavioral (rather than a medical) problem further exacerbate this uncertainty. Furthermore, the limited number and capacity of treatment facilities restricts market opportunities, as does the lack of medical treatment models. Finally, the substance abuse treatment market relies heavily on State and Federal reimbursement. Most substance abuse treatment services are subsumed under the mental health benefits of entitlement programs, and drug companies are reluctant to rely upon this kind of reimbursement in an age of shrinking budgets for mental health services.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Kevin Hennessy

PHONE NUMBER: (202) 690-7272

PIC ID: 6694

PERFORMER ORGANIZATION: The Lewin Group, Fairfax, VA

TITLE: Consumer-Directed Personal Assistance Services: Key Operational Issues for State CD-PAS Programs Using Intermediary Service Organizations

ABSTRACT: This study was undertaken by the Office of the Assistant Secretary for Planning and Evaluation (OASPE) to identify best practices for implementing consumer-directed personal assistance (CD-PAS) programs through the use of various intermediary service organization (ISO) models. This report provides practical advice to State program administrators about the design and implementation of CD-PAS programs with ISOs in order that: (1) they comply with Federal tax and labor laws; (2) they make available supportive services that some consumers may want or need; and (3) they allow for the application and enforcement of any limitation or restrictions on consumer direction that may be required by State laws and regulations. The report draws a number of conclusions that cut across ISO models, including (1) that the most successful State-ISO contract relationships are forged when the State has a clear understanding of the services that it wishes to purchase from the ISO; (2) that consumers' backup plans for relief attendants frequently fail, causing consumers to have a difficult time finding relief attendants over weekends, holidays, and when the primary attendant is absent for any reason; (3) that consumers are reluctant to initiate criminal background checks on prospective attendants because they do not know how to conduct them and they feel these checks compromise the consumer-attendant relationship; and (4) that a number of disability advocates and CD-PAS consumers expressed concern about the potential impact of managed care on the availability of CD-PAS to eligible consumers. The report also makes recommendations on how to address these problems. (Final report: 70 pages; appendices bound separately.)

AGENCY SPONSOR: Office of Disability, Aging, and Long-Term Care Policy

FEDERAL CONTACT: Floyd Brown

PHONE NUMBER: (202) 690-6613

PIC ID: 6728

PERFORMER ORGANIZATION: SysteMetrics, Cambridge, MA

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