[Senate Report 107-158]
[From the U.S. Government Publishing Office]
107th Congress SENATE Rept. 107-158
2d Session Volume 2
_______________________________________________________________________
DEVELOPMENTS IN AGING: 1999 AND 2000-VOLUME 2
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A REPORT
of the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
pursuant to
S. RES. 54, SEC. 17(c), MARCH 8, 2001
Resolution Authorizing a Study of the Problems of the Aged and Aging
June 4, 2002.--Ordered to be printed
DEVELOPMENTS IN AGING: 1999 AND 2000--VOLUME 2
_______________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001
SPECIAL COMMITTEE ON AGING
JOHN B. BREAUX, Louisiana, Chairman
PHARRY REID, Nevada LARRY CRAIG, Idaho, Ranking Member
HERB KOHL, Wisconsin CONRAD BURNS, Montana
JAMES M. JEFFORDS, Vermont RICHARD SHELBY, Alabama
RUSSELL D. FEINGOLD, Wisconsin RICK SANTORUM, Pennsylvania
RON WYDEN, Oregon SUSAN COLLINS, Maine
BLANCHE L. LINCOLN, Arkansas MIKE ENZI, Wyoming
EVAN BAYH, Indiana TIM HUTCHINSON, Arkansas
THOMAS R. CARPER, Delaware JOHN ENSIGN, Nevada
DEBBIE STABENOW, Michigan CHUCK HAGEL, Nebraska
JEAN CARNAHAN, Missouri GORDON SMITH, Oregon
Michelle Easton, Staff Director
Lupe Wissel, Ranking Member Staff Director
LETTER OF TRANSMITTAL
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U.S. Senate,
Special Committee on Aging
Washington, DC, 2002.
Hon. Dick Cheney,
President, U.S. Senate,
Washington, DC.
Dear Mr. President: Under authority of Senate Resolution 54
agreed to March 8, 2001, I am submitting to you the annual
report of the U.S. Senate Special Committee on Aging,
Developments in Aging: 1999 and 2000, volume 2.
Senate Resolution 4, the Committee Systems Reorganization
Amendments of 1977, authorizes the Special Committee on Aging
``to conduct a continuing study of any and all matters
pertaining to problems and opportunities of older people,
including but not limited to, problems and opportunities of
maintaining health, of assuring adequate income, of finding
employment, of engaging in productive and rewarding activity,
of securing proper housing and, when necessary, of obtaining
care and assistance.'' Senate Resolution 4 also requires that
the results of these studies and recommendations be reported to
the Senate annually.
This report describes actions taken during 1999 and 2000 by
the Congress, the administration, and the U.S. Senate Special
Committee on Aging, which are significant to our Nation's older
citizens. It also summarizes and analyzes the Federal policies
and programs that are of the most continuing importance for
older persons and their families.
On behalf of the members of the committee and its staff, I
am pleased to transmit this report to you.
Sincerely,
John B. Breaux, Chairman.
C O N T E N T S
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Page
Letter of Transmittal............................................ III
Item 1. Department of Agriculture............................ 1
Cooperative Extension System............................. 1
Agricultural Research Service............................ 2
Economic Research Service................................ 3
Food and Nutrition Service............................... 4
Center for Nutrition Policy and Promotion................ 7
Food Safety and Inspection Service....................... 7
Marketing and Regulatory Programs........................ 8
Item 2. Department of Commerce............................... 9
Item 3. Department of Defense................................ 17
Item 4. Department of Education.............................. 20
Item 5. Department of Energy................................. 54
Item 6. Department of Health and Human Services.............. 60
Administration for Children and Families................. 60
Administration on Aging.................................. 67
Office of the Assistant Secretary for Planning and
Evaluation............................................. 92
Centers for Disease Control and Prevention............... 102
Food and Drug Administration............................. 129
Health Care Financing Administration..................... 154
National Institutes of Health............................ 220
Health Resources and Services Administration............. 275
Office of Inspector General.............................. 290
Item 7. Department of Housing and Urban Development......... 295
Item 8. Department of the Interior.......................... 307
Item 9. Department of Justice............................... 318
Item 10. Department of Labor................................. 330
Item 11. Department of State................................. 345
Item 12. Department of Transportation........................ 347
Item 13. Department of the Treasury.......................... 359
Item 14. Commission on Civil Rights.......................... 377
Item 15. Consumer Product Safety Commission.................. 379
Item 16. Corporation for National Service.................... 385
Item 17. Environmental Protection Agency..................... 399
Item 18. Equal Employment Opportunity Commission............. 400
Item 19. Federal Communications Commission................... 430
Item 20. Federal Trade Commission............................ 445
Item 21. General Accounting Office........................... 530
Item 22. Legal Services Corporation.......................... 628
Item 23. National Endowment for the Arts..................... 629
Item 24. National Endowment for the Humanities............... 648
Item 25. Pension Benefit Guaranty Corporation................ 654
Item 26. Postal Service...................................... 691
Item 27. Railroad Retirement Board........................... 698
Item 28. Small Business Administration....................... 704
Item 29. Social Security Administration...................... 705
Item 30. Veterans' Affairs................................... 710
107th Congress Rept. 107-158
2d Session SENATE Volume 2
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DEVELOPMENTS IN AGING: 1999 AND 2000
VOLUME 2
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June 4, 2002.--Ordered to be printed
_______
Mr. Breaux, from the Special Committee on Aging, submitted the
following
R E P O R T
Report from Federal Departments and Agencies
ITEM 1--AGRICULTURE
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COOPERATIVE STATE RESEARCH, EDUCATION AND EXTENSION SERVICE (CSREES)
Since early 1999, USDA's CSREES has been working with
families with older Americans in small towns and rural areas to
make improved health care decisions. One of the strategies
focuses on how 4-H Youth Technology Teams can help other
Americans to bridge the Digital Divide. The program is known as
Teens Teaching Internet Skills (TTIS). In a partnership with
the Health Care Finance Administration, 4-H Technology
Leadership Teams are helping families with older Americans to
learn how to use the internet to improve the quality of
decisions they make in choosing health care, housing and
transportation. As a result of collaboration between young 4H
member volunteers and older Americans, seniors are increasingly
accessing internet web sites such as www.medicare.gov,
www.seniors.gov and www.workers.gov.
In 1999, 4-H Youth Technology piloted Teens Teaching
Seniors State Teams in Maryland, Virginia, Connecticut,
Florida, Iowa and Washington to test approaches to help older
adults to gain Internet skills. At the National Youth
Technology Conference, held in July 2000 in College Park,
Maryland, more than 250 youth leaders from 29 States met and
learned from the six original teams, and, since then, twenty-
nine States have taken the initiative to develop State action
plans and to identify state youth technology leadership
teams that, when provided with proper resources, will be able
to implement efforts for their own TTIS program. Many of the
individual State action plans call for the establishment of
Community Technology Centers to serve as learning centers where
youth can take the role of mentors to adults in helping them
become technologically literate. Many States are planning
public-private partnerships to establish technology learning
places in their communities. Today, 4-H Youth Technology teams
are converting the digital into digital opportunity across the
generations. Communities are now seeking support to grow these
efforts especially in under-served communities.
CSREES provided key leadership in the framing of a new
national extension initiative ``Financial Security in Later
Life,'' which will be implemented in FY 2001. The purpose of
the initiative is to focus new resources of the Land-grant
University System on research, resident education, and
extension/outreach programs related to an aging population.
Particular attention will be paid to retirement planning
especially the potential financial effects of long term care on
family finances. A significant contribution of USDA-CSREES will
be partnership building with other Federal agencies, the
financial services sector, foundations, and non-profit
organizations. Work already is underway on training for
extension educators, research on retirement issues of farm
families, and an interactive web site for consumers on long
term care decisions. It is expected the initiative will span 5
years.
AGRICULTURAL RESEARCH SERVICE (ARS)
The Department of Agriculture Research Service (ARS)
conducts research at the Jean Mayer Human Nutrition Research
Center on Aging (HNRCA) in Boston, Massachusetts, on behalf of
older Americans. Center scientists are determining the ways in
which diet and nutritional status influence the onset and
progression of aging, employing experimental animals, tissue
cultures, and human subjects for such studies. They are
exploring the ways in which diet, alone and in association with
other factors, can delay or prevent the onset of degenerative
conditions commonly associated with the aging process. This
research will determine nutrient requirements during aging and
the ways in which an optimal diet, in combination with
exercise, genetic, physiological, psychological, sociological
and environmental factors, may provide health and vigor over
the life span of man.
Scientists at the HNRCA are addressing three general
questions of central importance to this mission:
How does nutrition influence the progressive
loss of tissue functions with aging?
What is the role of nutrition in the genesis
of major chronic degenerative conditions associated
with the aging process?
What are the nutrient requirements necessary
to maintain the optimal functional well-being of older
people?
ARS is strengthening its integrated multidisciplinary human
nutrition research program to develop means for promoting
optimum human health and well-being through improved nutrition.
ARS research is also seeking to improve understanding of the
functional roles dietary patterns play in human health
maintenance. The goals of the ARS Human Nutrition Initiative
are to:
Reduce health care costs and enhance the
quality of life.
Improve the scientific basis for more
effective Federal food assistance programs.
Generate a more nutritious food supply.
Improve the resistance to acute infections
and immune disorder.
Enhance the capacity to promote changes in
diet habits.
Individualize dietary guidance for
nutritionally vulnerable groups within the United
States.
The ARS Human Nutrition Initiative Focuses on Five Vital
Concerns:
Food, Phytonutrients, and Health
Health Body Weight
Brain Function/Resistance to Mental Decline
Bone Growth and Protection from Osteoporosis
Foods to Fight Infectious Disease
Recent accomplishments include findings that fortification
or folate has reduced the prevalence of low circulating folate
and high homocysteine concentrations. The implementation of the
FDA-mandated folic acid fortification of enriched grain
products was completed by early 1998. Researchers at HNRCA
assessed the impact of fortifi-cation on the folate status of
adult Americans. They have conducted a long-term follow-up of
folate and homocysteine concentrations in the population-based
Framingham Heart Studies. This work indicated that the current
levels of fortification were able to reduce the prevalence of
low circulating folate and high homocysteine concentrations to
levels seen in multivitamin supplement users. This was the
first demonstration of the effectiveness of this important
national program.
Researchers at HNRCA in collaboration with Framingham
Osteoporosis Study researchers evaluated associations between
dietary vitamin K intake, apoE genotype, bone mineral density
and rate of hip fracture among elderly men and women
participating in the original cohort of the Framingham Health
Study. Low vitamin K intakes were significantly associated with
increased incidence of hip fractures in men and women. In
contrasts, neither low intakes of vitamin K nor apoE4 allele
were associated with low bone mineral density.
ECONOMIC RESEARCH SERVICE (ERS)
The Economic Research Service identifies research and
policy issues relevant to the elderly population from the
perspective of rural development. Ongoing research looks at
demographic and socioeconomic characteristics of the older
population by rural-urban residence. Current research examines
rural-urban differences in health and access to health care for
the elderly, based on data from the Current Population Survey
and National Health Interview Survey. In the past year, we
participated in the Interagency Forum on Aging-Related
Statistics, reviewed proposals for the Office of Rural Health
Policy's Rural Health Analytic Research Center Cooperative
Agreement Program, and contributed to the Conference Report
from the National Rural Health Research Agenda Setting
Conference.
The following publications on the rural elderly have been
prepared by ERS staff in the past year:
Rogers, Carolyn C., ``Growth of the Oldest Old Population
and Future Implications for Rural America,'' Rural Development
Perspectives, Vol. 14, No. 3, October 1999.
Rogers, Carolyn C., ``Changes in the Older Population and
Implications for Rural Areas, RDRR-90, December 1999 (released
Feb. 2000).
Rogers, Carolyn C., ``The Graying of Rural America,'' Forum
for Applied Research and Public Policy, December 2000.
FOOD AND NUTRITION SERVICE (FNS)
Title and purpose statement of each program or activity which affects
older Americans
The Food Stamp Program (FSP) provides monthly benefits to
help low-income families and individuals purchase a more
nutritious diet. In fiscal year 1999, $18 billion in food
stamps were provided to a monthly average of 18 million
persons.
Households with elderly members accounted for approximately
20 percent of the total food stamp caseload. However, sinced
these households were smaller on average and had relatively
higher net income, they received only 8 percent of all benefits
issued.
Brief description of accomplishments
The FSP has been at the forefront of efforts to reduce
hunger and food insecurity among the elderly. The initiatives
include:
Development of a guide titled ``Help for the
Elderly and Disabled: A Primer for Enhancing the
Nutrition Safety Net for the Elderly and Disabled''
that was distributed to appropriate agencies and
organizations. The purpose of this guide is to: 1)
assist State policy makers and others in understanding
the special rules embedded in the Food Stamp Act of
1977 (as amended) and the FSP regulations for elderly
and disabled individuals, 2) assist States and others
in identifying participation barriers the elderly and
disabled face when seeking nutrition assistance through
the FSP, and 3) assist States and others in identifying
possible outreach activities to increase participation
among the elderly and disabled.
Development of easily reproducible posters
and fliers as part of a public information campaign to
increase awareness of the FSP among target audiences,
including the elderly.
Announcing the availability of $3 million
dollars in research grants to be awarded in January
2001 to improve FSP access through partnerships and new
technology. The purpose of the grants is to explore
various strategies to reach potentially eligible
households and to educate food stamp eligible persons
not currently participating in FSP about the benefits
of the Program and how to apply for these benefits. One
of the target populations for these grants is the
elderly.
The Food and Nutrition Service (FNS) continues to work
closely with the Social Security Administration (SSA) in order
to meet the legislative objectives of joint application
processing for Supplemental Security Income (SSI) households.
In response to recommendations for joint processing
improvements, FNS and SSA have stepped up efforts to ensure
that SSI applicants are counseled on their potential
eligibility to receive food stamps. Additionally, a joint
Supplemental Security Income/Food Stamp processing
demonstration--the South Carolina Combined Application Project
(SCCAP)--was begun in the fall of 1995. An independent
evaluation of SCCAP was completed in January 2000 and showed
that the rate of food stamp participation among SSI recipients
in South Carolina increased from 38 percent in 1994 to 50
percent in 1998 while the national rate decreased from 42
percent to 38 percent during the same period. Net potential
savings at the South Carolina Department of Social Services are
estimated at $575,000 per year. Based on the success of the
project, FNS agreed to extend SCCAP for a maximum of three
additional years (through September 2000). During this time,
Congress will have a chance to review the findings of the
evaluation and determine whether the results warrant amending
the Food Stamp Act so that South Carolina may continue to use
the special provisions of SCCAP as part of its normal FSP
operations.
Commodity Supplemental Food Program (CSFP)
Title and purpose statement of each program or activity which affects
older Americans
The Commodity Supplemental Food Program provides
supplemental foods, in the form of commodities, and nutrition
education to infants and children up to age 6, pregnant,
postpartum or breastfeeding women, and the elderly (at least 60
years of age) who have low incomes and reside in approved
project areas.
Service to the elderly began in 1982 with pilot projects.
In 1985, allowed the participation of older Americans outside
the pilot sites if available resources exceed those needed to
serve women, infants and children. In fiscal year 1999,
approximately $45 million was spent on the elderly component.
Brief description of accomplishments
About 65 percent of total program spending provides
supplemental food to approximately 270,000 elderly participants
a month. Older Americans are served by 23 eligible State
agencies.
Food Distribution Program on Indian Reservations (FDPIR)
Title and purpose statement of each program or activity which affects
older Americans
The Food Distribution Program on Indian Reservations
provides commodity packages to eligible households, including
households with elderly persons, living on or near Indian
reservations. Under this program, commodity assistance is
provided in lieu of food stamps.
Approximately $27 million of total costs went to households
with a lease one elderly person. (This figure was estimated
using a 1990 study that found that approximately 39 percent of
FDPIR households had at least one elderly individual).
Brief description of accomplishments
This program serves approximately 15,000 households with
elderly participants per month.
Child and Adult Care Food Program (CACFP)
Title and purpose statement of each program or activity which affects
older Americans
The Child and Adult Care Food Program provides Federal
funds to initiate, maintain, and expand nonprofit food service
for children, the elderly, or impaired adults in nonresidential
institutions which provide child or adult care. The program
enables child and adult care institutions to integrate a
nutritious food service with organized care services.
The adult day care component permits adult day care centers
to receive reimbursement of meals and supplements served to
functionally impaired adults and to persons 60 years or older.
An adult day care center is any public or private nonprofit
organization or any proprietary Title XIX or Title XX center
licensed or approved by Federal, State, or local authorities to
provide nonresidential adult day care services to functionally
impaired adults and persons 60 years or older. In fiscal year
1999, $36 million was spent on the adult day care component.
Brief description of accomplishments
The adult day care component of CACFP served approximately
32 million meals and supplements to over 62,000 participants a
day in fiscal year 1999.
In 1993, the National Study of the Adult Component of CACFP
was completed. Some of the major findings of the study include:
overall, about 31 percent of all adult day care centers
participate in CACFP; about 43 percent of centers eligible for
the program participate. CACFP adult day care clients have low
incomes; 84 percent have incomes of less than 130 percent of
poverty. Many participants consume more than one reimbursable
meal daily; CACFP meals contribute just under 50 percent of a
typical participant's total daily intake of most nutrients.
The Emergency Food Assistance Program (TEFAP)
Title and purpose statement of each program or activity which affects
older Americans
The Emergency Food Assistance Program (TEFAP) provides
nutrition assistance in the form of commodities to emergency
feeding organizations for distribution to low-income households
for household consumption or for use in soup kitchens.
Approximately $17 million in commodities were distributed
to households including an elderly person. (This figure is
estimated using a 1986 survey indicating that about 38 percent
of TEFAP households have members 60 years of age or older.)
Brief description of accomplishments
About 38 percent of the households receiving commodities
under this program had at least one elderly individual.
Nutrition Program for the Elderly (NPE)
Title and purpose statement of each program or activity which affects
older Americans
The Nutrition Program for the Elderly provides cash and
commodities to States for distribution to local organizations
that prepare meals served to elderly persons in congregate
settings or delivered to their homes. The program addresses
dietary inadequacy and social isolation among older
individuals. USDA currently supplements the Department of
Health and Human Services' Administration on Aging with
approximately $141 million worth of cash and commodities.
Brief description of accomplishments
In fiscal year 1999, over 247 million meals were reimbursed
at a cost of almost $150 million. On a average day
approximately 932,000 meals were provided.
CENTER FOR NUTRITION POLICY AND PROMOTION (CNPP)
On September 28, 2000, CNPP hosted a symposium titled
``Nutrition and Aging: Leading a Healthy, Active Life.'' This
is the fifth in a series of symposiums hosted by CNPP that has
included topics such as Childhood Obesity, Breakfast and
Learning in Children, and Dietary Behavior. The purpose of the
symposiums is to provide participants with the latest available
scientific information, to increase the awareness of important
nutritional issues, and to examine how these issues influence
nutrition policy.
The following publication on the elderly have been prepared
by CNPP staff in calendar years 1999-2000:
Sahyoun, Nadine and Basiotis, P. Peter, ``Food
Insufficiency and the Nutritional Status of the Elderly
Population,'' Nutrition Insights, Insight #18, May 2000.
Gaston, Nancy W., Mardis, Anne, Gerrior, Shirley, Sahyoun,
Nadine, and Anand, Rajen S, ``A Focus on Nutrition for the
Elderly: It's Time to Take a Closer Look,'' `Nutrition
Insights, Insight #14, July 1999.
FOOD SAFETY INSPECTION SERVICES (FSIS)
New Education Program for Seniors:
With input from experts on aging, the Food Safety and
Inspection Service has worked cooperatively with the Food and
Drug Administration to produce a new educational program for
seniors: a 14 minute video and accompanying publication both
titled To Your Health, Food for Seniors.
In developing this educational program, FSIS staff drew on
the expertise of varied groups including the Administration on
Aging, the National Institutes of Health, AARP and the State
Units on Aging. As a result of those consultations, the program
materials are targeted to address unique behaviors that can
contribute to the risks of foodborne illness for seniors. They
are also presented in formats designed to be ``senior
friendly.'' The 17-page publication is printed in 14 point type
to make reading easier to older eyes. The publication is
presented in a large format--8\1/2\ by 11 inches--to make it
easy to hold and use. The video presents information in a clear
and concise manner with key points highlighted and repeated for
emphasis. The video is broken into two segments, one addressing
safe food handling at home and the other, food safety when
eating out.
The key food safety messages in the campaign--clean,
separate, cook and chill--are drawn from the national food
safety education campaign called Fight BAC!
Support of these four key food safety messages is a goal of
Healthy People 2010 and the new Dietary Guidelines for
Americans.
The educational program will be distributed early in 2001
and will include distribution to the Administration on Aging's
area offices and direct mail to more than 10,000 senior
centers. The publication will also be available through the
Consumer Information Center in Pueblo, CO. In all, more than a
half a million copies of the publication and nearly 50,000
copies of the video will be distributed.
On-going Food Safety Advice for Seniors:
To help communicate the importance of safe food handling
for seniors--and their special risks--all press releases issued
by FSIS include a box with safe food handling advice for at-
risk audiences. This advice is also routinely featured in video
news releases as well as feature stories. The Food Safety
Education staff also develops special features and fact sheets
designed to help educate seniors about safe food handling--
available through the FSIS web site: http://www.fsis.usda.gov/
oa/pubs/consumerpubs.htm
MARKETING AND REGULATORY PROGRAMS
The Agricultural Marketing Service facilitates the
accessibility of agricultural products to older Americans by
promoting and developing wholesale, collection, farmers, and
direct markets. The support provided for these markets has made
fresh, nutritious foods available in communities where older
Americans have previously not had access to such products. The
number of farmers markets has increased from 1,755 in 1994 to
over 2,800 in 2000.
ITEM 2--DEPARTMENT OF COMMERCE
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UPDATES TO THE DEVELOPMENTS IN AGING REPORT FOR 1999 AND 2000
This report provides short descriptions and listings of
products that contain demographic and socioeconomic information
on the elderly population, 65 years of age and older, in the
United States and abroad. All of the items included in this
report were released by the U.S. Census Bureau during calendar
years 1999 and 2000.
The items listed are available to the public in a variety
of formats including print, electronic data bases,
microcomputer diskettes, and CD-ROM. Many of these products can
be found on the Internet at the Census Bureau's Web site at:
.
1. Population, Housing, and International Reports.--Three
of the Census Bureau's major report series (Current Population
Reports, Current Housing Reports, and International Population
Reports) are important sources of demographic information on a
wide variety of population-related topics. This includes
information on the United States' elderly population, ranging
from their numbers in the total population to socioeconomic
characteristics, such as income, health insurance coverage,
need for assistance with activities of daily living, and
housing situation. Data on the elderly around the world also
are found in these series of reports.
Much of the data used in Current Population Reports are
derived from the Current Population Survey (CPS) and the Survey
of Income and Program Participation (SIPP). The Current Housing
Report series presents housing data primarily from the American
Housing Survey, a biennial national survey of approximately
55,000 housing units. The International Population Report
series includes demographic and socioeconomic data reported by
various national statistical offices, such as the National
Institute on Aging, agencies of the United Nations, and the
Organization for Economic Cooperation and Development.
Additionally, the Census Bureau's population projection
program and Special Studies Report series contain information
about the future estimated size of the elderly population and
information pertaining to statistical methods, concepts, and
specialized data.
2. Decennial Products.--A large number of printed reports,
computer tape files, CD-ROMs, and summary tape files are
produced after each decennial census. Included in these
materials are information and data on the numbers and
characteristics of persons 65 years of age and older.
3. Data Base on Aging/National Institute on Aging
Products.--The data provide a summary of analytical studies and
other ongoing international aging products. Reports are based
on compilations of data obtained from statistical offices of
individual countries, various international organizations, and
estimates and projections prepared at the Census Bureau. This
work is funded by the National Institute on Aging.
4. Federal Interagency Forum on Aging-Related Statistics
Summary.--The Forum, for which the Census Bureau is one of the
lead agencies, encourages cooperation, analysis, and
dissemination of data pertaining to the older population. A
summary of the activities of the Forum lists a number of aging-
related statistics.
5. Other Products.--In addition to the major products
listed separately, we include a list of other data products
that contain demographic and socioeconomic information on the
elderly population.
1. POPULATION, HOUSING, AND INTERNATIONAL REPORTS
Population
Report Number
Series P-20 (Population Characteristics):
Regularly recurring reports in this series contain data from
the Current Population Survey. Topics include geographical
mobility, fertility, school enrollment, educational
attainment, marital status and living arrangements,
households and families, the Black and Asian and Pacific
Islander populations, persons of Hispanic origin, voter
registration and participation, and various other topics for
the general population, as well as the elderly population 65
years and older.
School Enrollment--Social and Economic Characteristics of
Students: October 1997...................................... 516
The Foreign-Born Population in the United States: March 1999.. 519
Geographical Mobility 1997 to 1998............................ 520
School Enrollment--Social and Economic Characteristics of
Students: (Update) October 1998............................. 521
Computer Use in the United States: October 1997............... 522
Voting and Registration in the Election of November 1998...... 523RV
The Hispanic Population in the United States: March 1998...... 525
Fertility of American Women: June 1998........................ 526
The Hispanic Population in the United States: March 1999...... 527
Educational Attainment in the United States: March 1999....... 528
The Asian and Pacific Islander Population in the United
States: March 1999.......................................... 529
The Black Population in the United States: March 1999......... 530
Geographical Mobility (Update): March 1998 to March 1999...... 531
The Older Population in the United States: March 1999......... 532
Series P-23 (Special Studies):
Information pertaining to methods, concepts, or specialized
data is furnished in these publications. Reports in this
series contain data on mobility rates, home ownership rates,
and the Hispanic population for both the general and older
populations.
Profile of the Foreign--Born Population in the United States.. 195
Trends in Premarital Childbearing............................. 197
Coresident Grandparents and Grandchildren..................... 198
Centenarians in the United States............................. 199RV
Geographical Mobility: 1990-1995.............................. 200
Poverty Among Working Families: Findings From Experimental
Poverty Measures 1998....................................... 203
Series P-25 (Population Estimates and Projections):
Population estimates data include monthly estimates of the
total U.S. population; annual midyear estimates of the U.S.
population by age, sex, race, Hispanic origin (nativity was
added for the 1998 series of estimates); States by age and
sex; and population totals for counties, metropolitan areas,
and approximately 36,000 cities and other local governments.
The estimates for counties appeared in Series P-26 during
the 1970s and 1980, as did estimates for the approximately
36,000 local governments during the 1980s. Estimates for
Puerto Rico and the outlying areas were published in Series
P-25 through the 1980s. Estimates of the population for
Puerto Rico, outlying areas, and United States and state
housing unit estimates are available in the P-25 series and
more recently in press releases mentioned in this
publication. At present, most estimates formerly published
in the P-25 series are released only through the Internet,
with future plans to archive annual estimates data on CD-
ROM.
Projections of the United States and state populations are
also included in the P-25 series. Beginning in the 1980's,
projections are available not only by age and sex, but also
by race and Hispanic origin. There also can be occasional
research/developmental reports in this series. The Census
Bureau's plan for releasing projections include CD-ROM and
the Internet.
Population Trends in Metropolitan Areas and Central Cities.... 1133
Population Estimates available on the Census Bureau's Web site
National Population Estimates:
Annual Population Estimates--Median and Mean Age; 5-year Age
Groups; Sex; and Special Age Categories for Selected Years
from 1990 to 2000. July 1 dates, plus the most recent month
for which data are available.
Annual Population Estimates by Age, Sex, Race and Hispanic
Origin; Median Age; Sex; Race (White; Black; American
Indian, Eskimo, and Aleut; and Asian and Pacific Islander);
Hispanic (of any race) and Non-Hispanic by Race for Selected
Years 1990 to 2000. July 1 dates, plus the most recent month
for which data is available.
Population by Nativity--National Population Estimates by
Nativity from 1990-1999 (Includes age).
State Population Estimates (Includes: U.S. Regions, Divisions, and
States):
1990 to 1999 Annual Time Series of State Population Estimates
by Age and Sex; By 5-Year Age Groups and Sex, Selected Age
Groups and Sec, and Single Year of Age and Sex, Median Ages:
1990 and 1999.
1990 to 1999 Annual Time Series of State Population Estimates
by Race and Hispanic Origin: By Age, Sex, Race, and Hispanic
Origin.
County Population Estimates:
1990 to 1999 Annual Time Series of County Population Estimates
by Age, Sex, Race and Hispanic Origin: By Age, Sex, Race,
Hispanic Origin, and Selected Age Groups.
Household and Housing Unit Population Estimates:
Housing Units, Households, Households by Age of Householder,
and Persons per Household for States: 1998 Estimates, 1990
Census, 1990 to 1998 Percent Change, 1990 to 1998 Numeric
and Percent Change, 1998 Percent Distribution of Households
by Age of Householder, 1990 to 1998 Annual Time Series.
Population Projections
National Population Projections:
The Population Projections Program produces projections of the
United States resident population by age, sex, race,
Hispanic origin, and nativity. The projections are based on
assumptions about future births, deaths, and international
migration. Although alternative series are produced, the
preferred, or middle series, is most commonly used. The
Census Bureau releases new national population projections
periodically.
Press Releases Available on Population Projections:
(NP-T3) Projections of the Total Resident Population by 5-Year
Age Groups and Sex with Special Age categories: Middle
Series, 1999 to 2100.
(NP-T4) Projections of the Total Resident Population by 5-Year
Age Groups, Race, and Hispanic Origin with Special Age
categories: Middle Series, 1999 to 2100.
(NP-D1-A) Annual Projections of the Resident Population by
Age, Sex, Race, and Hispanic Origin: Lowest, Middle,
Highest, and Zero International Migration Series, 1999 to
2100.
(NP-D1-B) Quarterly Projections of the Resident Population by
Age, Sex, Race, and Hispanic Origin: Middle Series, January
1, 1999 to January 1, 2101.
(NP-D2) Projections of the Foreign-Born Population by Age,
Sex, Race, and Hispanic Origin: Lowest, Middle, Highest
Series, 1999 to 2100.
(NP-D5) Components of Change: Component Assumptions of the
Resident Population by Age, Sex, Race, and Hispanic Origin:
Lowest, Middle, Highest Series, 1999 to 2100.
Population Pyramids: Total Population by 5-Year Age Groups:
1990, 2000, 2025, 2050, 2100.
Series PPL (Population Paper Listings):
This series of reports contains estimates of population and
projections of the population by age, sex, and origin. Other
topics appear as well some of which address issues related
to aging.
The Asian and Pacific Islander Population in the United
States: March 1998 (Update)................................. 113
Computer Use in the United States: October 1997............... 114
Profiles of the Foreign-Born Population in the United States:
1997........................................................ 115
Fertility of American Women: June 1998........................ 116
The Foreign-Born Population in the United States: March 1998.. 117
Geographical Mobility: March 1997 to March 1998............... 118
School Enrollment--Social and Economic Characteristic of
Students: October 1998 (Update)............................. 119
Voting and Registration in the Election of November 1998...... 120
Foreign-Born Population in the United States: March 1999...... 123
The Hispanic Population in the United States: March 1999...... 124
Educational Attainment in the United States: March 1999....... 125
Foreign-Born People in the United States: March 1995.......... 127
Foreign-Born People in the United States: March 1996.......... 128
Foreign-Born People in the United States: March 1997.......... 129
The Black Population in the United States: March 1999 (Update) 130
The Asian and Pacific Islander Population in the United
States: March 1999 (Update)................................. 131
Geographical Mobility: March 1998 to March 1999............... 132
The Older Population in the United States: March 1999......... 133
Geographical Mobility: 1990-1995.............................. 137
Who is Minding the Kids? Child Care Arrangements Fall 1995.... 138
Technical Working Papers Series:
This series contains papers of a technical nature on various
topics, which have been written by staff of the Population
Division of the Census Bureau. Evaluation of population
projections, estimates and 1990 Census results, examination
of immigration issues, race and ethnic considerations, and
fertility patterns are some of those topics.
``Are There Differences in Voting Behavior Between Naturalized
and Native-born Americans?'' by Loretta E. Bass and Lynn M.
Casper, Issued 1999......................................... 28
``Historical Census Statistics on the Foreign-born Population
of the United States: 1850-1990 by Campbell J. Gibson,
Issued February 1999........................................ 29
Women's Labor Force Attachment Patterns and Maternity Leave: A
Review of the Literature by Kristen E. Smith and Amara
Bachu, Issues January 1999.................................. 32
Evaluation of Relationship, Marital Status, and Grandparents
Items on the Census 2000 Dress Rehearsal by Charles Clark
and Jason Fields, Issued April 1999......................... 33
Unbinding the Ties: Edit Effects of Marital Status on Same
Gender Couples by Jason Fields and Charles Clark, Issued
April 1999.................................................. 34
Racial-Ethnic and Gender Differences in Returns to
Cohabitation and Marriage: Evidence from the Current
Population Survey by Philip N. Cohen, Issued May 1999....... 35
How Does POSSLQ Measure Up? Historical Estimates of
Cohanitation by Lynne M. Casper, Philip N. Cohen, and Tavia
Simmons, Issued May 1999.................................... 36
Is Childlessness Among American Women on the Rise? by Amara
Bachu, Issued May 1999...................................... 37
Population Projections of the United States, 1999 to 2100:
Methodology and Assumptions by Frederick Hollmann, Tammany
Mulder, and Jeffrey Kallan, Issued January 2000............. 38
What Do We Know About the Undercount of Children? by Kristin
K. West and J. Gregory Robinson, Issued August 1999......... 39
Measures of Help Available to Households in Need: Their
Relation to Well-being, Welfare, and Work by Kurt J. Bauman
and Barbara Downs, Issued May 2000.......................... 42
Have We Reached the Top? Educational Attainment Projections of
the U.S. Population by Jennifer Cheeseman Day and Kurt J.
Bauman, Issued May 2000..................................... 43
The Effects of Work and Welfare on Living Conditions in Single
Parent Households, by Kurt J. Barman, Issued August 2000.... 46
Series SB/CENBR (Statistical Briefs):
These are succinct reports that are issued occasionally and
provide timely data on specific issues of public policy.
Presented in narrative style with charts, the reports
summarize data from economic and demographic censuses and
surveys. In December 1996, the Statistical Brief series
format was revised and became known as Census Briefs.
Women in the United State: A Profile.......................... 00-1
Coming to America: A Profile of the Nation's Foreign-Born..... 00-2
From the Mideast to the Pacific: A Profile of the Nation's
Asian Foreign-Born Population............................... 00-4
Series P-60 (Consumer Income):
This series of reports presents data on the income, poverty
and health insurance status of households, families, and
people in the United States.
Child Support for the Custodial Mothers and Fathers: 1995..... 196
The Changing Shape of the Nation's Income Distribution: 1947-
1998........................................................ 204
Experimental Poverty Measures................................. 205
Money Income in the United States: 1998....................... 206
Poverty in the United States: 1998............................ 207
Health Insurance Coverage: 1998............................... 208
Money Income in the United States: 1999....................... 209
Poverty in the United States: 1999............................ 210
Health Insurance Coverage: 1999............................... 211
Child Support for the Custodial Mothers and Fathers: 1997..... 212
Series P-70 (Household Economic Studies):
These data are from the Survey of Income and Program
Participation (SIPP), a national survey conducted by the
Census Bureau. Its principal purpose is to provide better
estimates of the economic situation of families and
individuals. These reports include data on the elderly
population 65 years and older.
Financing the Future: Postsecondary Students, Cost, and
Financial Aid............................................... 60
Extended Measures of Well-Being: Meeting Basic Needs.......... 67
Dynamics of Economic Well-Being: Program Participation, Who
Gets Assistance?............................................ 69
Housing
These data are from the American Housing Survey. The survey
presents data on apartments; single-family homes; mobile
homes; vacant housing units; age, sex, and race of
householders; housing and neighborhood quality; housing
costs; equipment and fuels; and size of housing units.
Reports are present data on homeowner's repairs and
mortgages, rent control, rent subsidies, previous units of
recent movers, and reasons for moving. A wall chart
accompanies each report.
Series H-170 (Housing Characteristics for Selected Metropolitan
Areas):
A separate report present data for individual metropolitan
areas for the same characteristics shown in Series H-150.
Eleven to 13 metropolitan areas are interviewed each year.
They are surveyed on a rotating basis, with a total of 48
metropolitan areas being surveyed within a 6-year period.
2. DECENNIAL PRODUCTS
Centenarians in the United States: 1990, Connie Krach and
Victoria A. Velkoff, Current Population Reports, Series P-23-
199, Washington, DC 1999.
State Chartbook on Aging, forthcoming. This report presents
state-level data for the population aged 65 and older for
several key indicators; population, race and ethnic group,
marital status, living arrangements, and poverty. Most of the
data are from the 1990 Census of Population and Housing for the
United States.
3. DATA BASE ON AGING/NATIONAL INSTITUTE ON AGING PRODUCTS
The following reports, articles, and book chapters are
based on information contained in the International DataBase on
Aging and other related holdings of the International Programs
Center, Population Division, Census Bureau. This work is
carried out with the support of the National Institute on Aging
and is intended to highlight the present and future worldwide
dimensions of aging and portray the diversity among nations.
``Gender Stereotypes: Data Needs for Aging Research.''
Victoria A. Velkoff and Kevin Kinsella. International Aging,
Spring 1998, Vol. 24, No. 4, pp. 18-38.
``Russia's Aging Population'' Victoria A. Velkoff and Kevin
Kinsella. In Russia's Torn Safety Nets, Mark G. Field and
Judyth L. Twigg, eds. St. Martin's Press, New York, 2000.
Work in Progress
An Aging World 2000, forthcoming. This report gives a
cross-national comparison of aging in 52 study countries. It
focuses on both the demographic aspect of aging in these
countries and the socioeconomic impact of aging. The report
highlight projected trends into the 21st century for the
world's older population.
Aging in Africa, forthcoming. This report examines the
demographic and socioeconomic characteristics of the older
population in Sub-Saharan Africa and will highlight the impact
of HIV/AIDS on the older populations in these countries.
World Population Profile: 2000, forthcoming. This report
provides comprehensive demographic data for all countries and
regions of the world. There are two special focus sections in
the report, ``Child Mortality in the Developing World'' and
``Focus of the AIDS Pandemic in the 21st Century.''
4. THE FEDERAL INTERAGENCY FORUM ON AGING-RELATED STATISTICS SUMMARY
The Census Bureau is one of the convening agencies in the
Federal Interagency Forum on Aging-Related Statistics. The
Forum, begun in the mid-1980s, was the first-of-its-kind effort
to coordinate data and efforts of different government
agencies. The Forum currently is being managed by staff of the
National Center for Health Statistics, with the support of the
National Institute on Aging.
The Forum encourages cooperation among federal agencies in
the development, collection, analysis, and dissemination of
data pertaining to the older population. Through coordinated
approaches, the Forum extends the use of limited resources
among agencies through joint problem-solving, identification of
data gaps, and improvement of statistical information bases on
the older population, which are used to set project priorities
of individual agencies.
The Forum goals include widening access to information on
the older population, promoting communication between data
producers and public policymakers, coordinating the development
and use of statistical databases among relevant federal
agencies, identifying information gaps/data inconsistencies,
and evaluating data quality. The work of the Forum facilitates
the exchange of information about needs at the time new data
are being developed or changes are being made in existing data
systems. It also promotes communication between data producers
and policymakers.
As part of the Forum's work to improve access to data on
the older population, in 1999, the Census Bureau published a
report entitled DataBase News in Aging, which includes
developments in databases of interest to researchers and others
in the field of aging. Much of the information comes from
government-sponsored surveys and products. All federal agencies
are invited to contribute to the report, which is produced in
hard copy and is available on the Census Bureau's Internet
site.
In 2000 the Forum produced the report, Older Americans
2000: Key Indicators of Well-Being. This report described the
overall status of the U.S. population 65 and over. It compiled
data to focus on several important areas in the lives of older
people--including economic status, health status, health risks
and behaviors, and health care.
5. OTHER PRODUCTS
Profile on Racial and Ethnic Diversity Among Older
Americans, forthcoming. This report focuses on racial and
ethnic differences in America's older population using data
from the Current Population Survey (CPS).
American Housing Survey
Computer data tapes and CD-ROM are available for the 1997
survey efforts. The survey is designed to provide information
on the housing situation in the United States. Information is
available by age.
CPS and Survey of Income and Program Participation
Data for both surveys are available in electronic media.
Statistical Abstract of the United States: 1999
As the National Data Book, these annually released products
contain an enormous collection of statistics on social and
economic conditions in the United States. Selected
international data also are included. The abstract appears in
both print and CD-ROM versions.
International DataBase
The International Data Base (IDB) is a computerized data
bank containing statistical tables of demographic and
socioeconomic data for all countries of the world. Most
demographic information comes from country-specific estimates
and projections made by the Census Bureau's International
Programs Center. Country-specific data on social and economic
characteristics are obtained from censuses and surveys or from
administrative records. Country files are regularly updated as
new information becomes available. Selected information from
the IDB is highlighted in the Census Bureau's various
international reports and publications mentioned previously.
ITEM 3--DEPARTMENT OF DEFENSE
----------
Eldercare Support
Military members and their families face unique challenges
when facing Eldercare issues. Military members and families are
often stationed far away from elderly relatives who may need
their assistance. These demands seem to be increasing as life
expectancies increase. Military families often find themselves
trying to deal long-distance, even from overseas, with finding
quality, affordable care for elderly family members. The
situation is often further complicated by military family
separations that are the norm of military life.
In the 1999 Department of Defense Survey of active duty
members, of those responding to the survey, we estimate that
4.1 percent of the force has caregiver responsibilities for
elderly loved ones. Of the 4.1 percent, 72 percent of those
indicated that they have responsibility for one elder person,
23.5 percent indicated responsibility for 2 elderly persons,
and 4.5 percent indicated responsibilities for 3 or more.
The Information and Referral (I&R) function of the
Department of Defense Family Support programs is a critical
source of information to families struggling to balance the
demands of military life with the need to ensure the well-being
and safety of elderly parents and loved-ones. Internet
resources have proved to be a valuable tool for family support
specialists who can research information and help military
families start on the right path in sifting through this
mountain of information. The I&R specialists often use the
Eldercare Locator which directs them to appropriate local
resources. The I&R specialists will filter a quantity of
information in order to assist the inquiring service member
with the appropriate resource and advice. While the assistance
family support I&R specialists can provide is limited, they
make every effort to connect military families with the best
and most reliable resources for making informed choices.
The I&R specialists often receive inquiries about making an
elderly loved one a legal dependent of the service member. The
specialists will caution the member to carefully consider this
option since the elderly loved one may lose state benefits if
they relocate with the service member. In addition, if they
become a legal dependent of the military person, they are not
eligible for TRICARE.
The Family Centers also have a number of useful pamphlets
and handouts on eldercare which they provide to military family
members seeking assistance for a particular eldercare issue.
The Family Centers often work with the local Retired Affairs
Offices across the country in sponsoring Retired Affairs
Seminars which draw thousands of military retirees and their
families. For these seminars, staff bring in experts to present
eldercare topics such as: long-term care insurance, respite
care, medical information, social security benefits and
eldercare legal issues. These seminars are an important vehicle
to update the military retiree community on current eldercare
issues.
Health Care
TRICARE is the health plan for uniformed services
beneficiaries. It is a regionally organized managed care
program that integrates the military health facilities of the
Army, Navy and Air Force and supplements the care these
facilities offer with civilian networks of providers. TRICARE
offers three choices for health care delivery: TRICARE Prime,
TRICARE Extra, and TRICARE Standard. TRICARE Prime, a voluntary
enrollment option, offers patients the advantage of primary
care management, assistance in making specialty appointments,
and additional preventive and primary care services. For
eligible beneficiaries, TRICARE Prime generally is the least
expensive option.
TRICARE Extra allows eligible beneficiaries to receive an
out-of-pocket discount when using preferred network providers.
Eligible beneficiaries who do not enroll in TRICARE Prime may
participate in Extra on a case-by-case basis just by using
network providers. Beneficiaries selecting TRICARE Extra do
incur deductibles and co-payments. TRICARE Standard offers
comprehensive healthcare coverage from any authorized provider.
Beneficiaries selecting this option incur deductibles and co-
payments at a slightly higher rate than those selecting TRICARE
Extra.
All active duty members enroll in TRICARE Prime without
cost to the member. Family members, survivors and retirees
under the age of 65 may enroll in TRICARE Prime. Retirees and
their family members pay a small enrollment fee and all
eligible beneficiaries except active duty members incur nominal
co-payments for care received from network providers. Care
received in military medical facilities is without cost to
beneficiaries; for those not enrolled in TRICARE Prime, care in
military medical facilities is received on a space available
basis.
During this reporting period, the law stipulated that
military retirees and their families up to age 65 are eligible
for the three TRICARE options. Military retirees and their
dependents over the age of 65 may not participate in TRICARE,
but they are eligible for care in military medical facilities
on a space available basis. Included in this space available
coverage are prescription drugs provided the needed medications
are on the facility's formulary. Additionally, the Department
of Defense sought ways to enhance its services to its over-65
beneficiaries through a number of demonstration programs.
Specifically, the Department tested alternatives to expand
healthcare coverage to Medicare-eligible beneficiaries through
Medicare reimbursement of military medical facilities, opening
access to the Federal Employee Health Benefit Program,
expanding pharmacy options, and offering supplemental coverage
to Medicare.
Implemention of the Floyd D. Spence National Defense
Authorization Act of fiscal year 01 will directly impact these
demonstration programs and significantly change the healthcare
coverage offered by the Department of Defense to its Medicare
eligible beneficiaries. This new legislation is the most
dramatic modification to military health care coverage since
the establishment of the Civilian Health and Medical Program of
the Uniformed Services in 1965. By April 2001, the Department
of Defense will offer these senior beneficiaries the same
prescription drug benefit enjoyed by other uniformed services
beneficiaries. They will continue to use the military
pharmacies with no cost for medications; and on April 1, 2001,
they will be entitled to use the mail order pharmacy program,
network retail and non-network retail pharmacies. Medications
through these sources will require a nominal copayment of $3
for generic and $9 for branded medications; by mail order
patients may receive up to a 90-day supply for this amount, and
in the network retail pharmacies they may receive up to a 30-
day supply for this amount. The non-network retail pharmacies
will cost a bit more. Also in the next year, senior
beneficiaries will become eligible for TRICARE for Life
benefits, the most significant of which is the secondary pay
program. Beginning October 1, 2001, TRICARE will supplement
Medicare benefits of these uniformed services beneficiaries,
and, in most cases, with no additional claims processing
required by the patient. To participate, these beneficiaries
must be eligible for Medicare Part A and enrolled in Medicare
Part B. They may continue to seek care from their Medicare
providers and have TRICARE pick up the cost of their
deductible, co-payments and other costs not paid by Medicare.
TRICARE will also cover any TRICARE benefit that Medicare does
not offer. Out-of-pocket expenses for these dual eligible
beneficiaries will be a nominal co-payment for medications and
Medicare Part B fees. This legislation brings to the senior
military retirees and their dependents a health benefit that is
unparalleled. It provides low-cost access to an extraordinary
range of healthcare benefits, and offers choice in selection of
providers. This legislation brings healthcare coverage by the
Department of Defense as an entitlement to our senior
beneficiaries.
ITEM 5--DEPARTMENT OF ENERGY
----------
Introduction
The Department of Energy (DOE) is a leading science and
technology agency whose research supports our nation's energy
security, national security, and environmental quality and
contributes to a better quality of life for all Americans. DOE
owns and manages more than 50 major installations located in 35
states, employing approximately 10,000 federal workers and
100,000 contract workers.
Science is at the center of DOE's work, performed in its 27
laboratories and other scientific user facilities and in the
nation's universities. DOE supports breakthrough research in
energy sciencesand technology, high energy physics, global
climate change, genome mapping and the bio-sciences,
superconducting materials, accelerator technologies,
environmental sciences, and super-computing. DOE also supports
science and mathematics education from the K-12 level through
post-doctoral work.
In support of the nation's energy security, DOE promotes
development of clean, secure, sustainable energy resources,
works to increase the diversity of energy supplies and fuel
choices, and maintains the Strategic Petroleum Reserve.
In fulfilling its national security mission, DOE assures
the safety and reliability of the U.S. nuclear weapons
stockpile without underground testing and supports U.S. non-
proliferation, arms control, and nuclear safety objectives
world-wide.
In meeting its environmental quality mission, DOE is
responsible for cleaning up the environmental legacy left at
sites where, for some 50 years, the nation's nuclear weapons
were designed and manufactured.
Energy Efficiency Programs
Weatherization Assistance Program--The program's mission is
to make energy more affordable and improve health and safety in
homes occupied by low-income families, particularly those with
elderly residents, children, or persons with disabilities.
Elderly residents make up approximately 40 percent of the low-
income households served by this program. As of September 30,
2000 about 4.9 million homes had been weatherized with federal,
state, and utility funds; of these, an estimated 2.0 million
were occupied by elderly persons.
Low-income households spend an average 15 percent of income
for residential energy more than four times the proportion
spent by higher income households. The weatherization program
allows low-income citizens to benefit from energy efficiency
technologies that are otherwise inaccessible to them.
Alleviating the high energy cost burden faced by low-income
Americans helps them increase their financial independence and
their flexibility to spend household income on other needs.
The program has become increasingly effective due to
improvements in air-leakage control, insulation, water heater
systems, windows and doors, and space heating systems. At
current prices, a weatherized low-income household now saves
approximately $250 per year, about one-third of its space
heating costs. Program benefits are further described in the
Progress Report of the National Weatherization Assistance
Program, available through the National Technical Information
Service, 703/487-4650, 5285 Port Royal Road, Springfield, VA
22161.
States implement the program through community-based
organizations. DOE and its state and community partners
weatherize approximately 70,000 single- and multi-family
dwellings each year. The program awarded $133 million in Fiscal
Year 1999 and $135 million in Fiscal Year 2000 for grants to
the 50 states, the District of Columbia, and six Native
American tribal organizations. In addition to DOE
appropriations, state and local programs receive funding from
the Department of Health and Human Services' Low Income Home
Energy Assistance Program, from utilities, and from states.
State Energy Program--The program provides grants to State
Energy Offices to encourage the use of energy efficiency and
renewable energy technologies and practices in states and
communities through technical and financial assistance. In
Fiscal Year 1999, $32 million wasappropriated for the program
and in Fiscal Year 2000, $33 million. States have broad
discretion in designing their projects. Typical project
activities include: public education to promote energy
efficiency; transportation efficiency and accelerated use of
alternative transportation fuels for vehicles; financial
incentives for energy conservation/renewable projects including
loans, rebates, and grants; energy audits of buildings and
industrial processes; development and adoption of integrated
energy plans; promotion of energy efficient residences; and
deployment of newly developed energy efficiency and renewable
energy technologies.
Some projects target the elderly specifically, such as
Louisiana's low-income/handicapped/elderly/Native American
outreach program which provides energy related assistance
through a joint venture with utilities. The elderly also
benefit from broader programs that provide energy audits,
hands-on energy conservation workshops, and low-interest loans
for homeowners. These can result in significant personal energy
savings. Energy efficiency improvements in local and state
buildings and services also indirectly benefit the elderly by
freeing up state and local government tax revenues for non-
energy needs, as do energy efficient schools which place less
of a burden on property taxes.
Information Collection and Distribution
The Energy Information Administration collects and
publishes comprehensive data on energy consumption through the
Residential Energy Consumption Survey (RECS). The RECS is
conducted in households quadrennially and collects data from
individual households throughout the country, including those
headed by elderly individuals. Along with household and housing
unit characteristics data, the RECS also collects the actual
billing data from the households' fuel suppliers for a 12-month
period.
The results of the RECS are analyzed and published by the
Energy Information Administration. The most recent survey data
are from the 1997 RECS and are published on the Internet at
http://www.eia.doe.gov/emeu/recs. The 1997 RECS public use data
files are also available at this site. These files will include
demographic characteristics of the elderly such as age, marital
status and household income, as well as estimates of
consumption and expenditures for electricity, natural gas, fuel
oil, kerosene, and liquefied petroleum gas used in elderly
households.
In the 1997 RECS, 28.5 million, or 28 percent of all U.S.
households, were headed by a person 60 years of age or older.
Of these elderly households, 44 percent were one-member
households (12.4 million people living alone) and 44 percent
contained two people. In 19 percent of the two-member elderly
households both members were under the age of 65; in 21 percent
of these households, only one member was younger than 65; and
in 60 percent, both members were over the age of 65.
Comparisons of elderly versus non-elderly households reveal
that:
The 1997 household income of elderly
households was generally lower than that of non-elderly
households. Nearly a quarter, 23 percent, of elderly
households had incomes of less than $10,000, compared
to 9 percent of the non-elderly households. Only 12
percent of the elderly households had incomes of
$50,000 or more, compared to 34 percent of the non-
elderly households. Of the 14.7 million U.S. households
whose income was below the poverty line, 37 percent
were headed by a person 60 years of age or older.
Despite having lower household incomes, the
elderly households were more likely to own their
housing unit, 80 percent, than were non-elderly
households, 63 percent. The elderly were also more
likely to live in a single-family house, 76 percent,
than were non-elderly households, 71 percent.
Elderly households are less likely to have a
personal computer or a modem connecting that computer
to the Internet or e-mail networks than are households
headed by persons less than 60 years of age. Among
elderly households, 14 percent have a personal computer
compared to 43 percent of the non-elderly households.
Only 7 percent of elderly households have a modem
connection compared to 26 percent of the non-elderly
households.
Elderly households are only marginally less
likely to have a microwave oven, 79 percent, than are
non-elderly households, 85 percent.
Analysis of the 1997 RECS data shows that consumption
patterns differed between the elderly and non-elderly for some
uses of energy. The elderly used more energy to heat their
homes but used less energy for air conditioning, water heating,
and appliances. Expenditures followed the same pattern.
Specifically,
The average expenditures per household
member in elderly households in 1997 was $708. This
amount was higher than the comparable amount for all
other households, due to the fact that households
headed by persons 60 years or more of age tend to be
smaller than those headed by persons under 60 years of
age.
About 58 percent of total energy consumption
and about 37 percent of total energy expenditures in
elderly households were for space heating. On the other
hand, appliances accounted for 23 percent of
consumption and 45 percent of total expenditures in
elderly households. Energy costs for appliances are
much higher relative to consumption than are energy
costs for space heating because virtually all
appliances are powered by electricity, the most
expensive energy source, whereas space heating is
largely provided by other, less expensive, energy
sources.
Research Related to Aging
Through fiscal year (FY) 2000, the Office of Environment,
Safety and Health (EH) sponsored research to further
understanding of the human health effects of radiation. As part
of this research program, DOE sponsored epidemiologic studies
concerned with understanding health changes over time. Lifetime
studies of humans constitute a significant part of EH's
research; and because the risks of various health effects vary
with age, these studies take age into consideration. EH
supports research to characterize late-appearing effects
induced by chronic exposure to low levels of physical agents,
as well as some basic research on certain diseases that occur
more frequently with increasing age.
Because health effects resulting from chronic low-level
exposure to energy-related toxic agents may develop over a
lifetime, they must be distinguished from normal aging
processes. To distinguish between induced and spontaneous
changes, information is collected from both exposed and non-
exposed groups on changes that occur throughout the life span.
These data help characterize normal aging processes and
distinguish them from the toxicity of energy-related agents.
Summarized below are specific research projects that the
Department sponsored in FY 2000.
Long Term Studies of Human Populations--Through EH, DOE
supports epidemiologic studies of health effects in humans who
may have been exposed to chemicals and radiation associated
with energy production or national defense activities.
Information on life span in human populations is obtained as
part of these studies. Because long-term studies of human
populations are difficult and expensive, they are initiated on
a highly selective basis.
The Radiation Effects Research Foundation, sponsored
jointly by the United States and Japan, continues to work on a
lifetime follow up of survivors of atomic bombings that were
carried out in Hiroshima and Nagasaki in 1945. Over 100,000
persons are under observation in this study. An important
feature of this study is the acquisition of valuable
quantitative data on dose-response relationships. Studies
specifically concerned with age-related changes are also
conducted. No evidence of radiation-induced premature aging has
been observed.
Multiple epidemiologic studies involving about 400,000
contract employees at DOE facilities are being managed by the
Department of Health and Human Services through a Memorandum of
Understanding between the two agencies. These studies include
assessments of health effects at older ages due to ionizing
radiation and other industrial toxicants. Several of the
studies will look closely at workers who were first exposed at
age 45 or older, assessing the impact of these late exposures
in relation to the burden of chronic diseases that are common
among older people. The average age of workers included in
these studies is greater than 50 years.
A recent study indicated that workers who were
occupationally exposed to radiation for the first time at age
45 or older might be more sensitive to health effects than
workers who were exposed at younger ages. However, very few
workers at DOE fit this profile. This finding is very
preliminary and further research and analyses are being
conducted to see if these results can be duplicated.
The United States Uranium/Transuranium Registry, currently
operated by Washington State University, collects occupational
data including work, medical, and radiation exposure histories
and information on mortality among workers exposed internally
to plutonium or other transuranic elements. Most of the workers
participating in this voluntary program are retirees.
In response to the Defense Authorization Act of 1993, EH
has established a program involving a number of ongoing
projects across the DOE weapons complex to identify former
workers whose health may have been placed at risk as a result
of occupational exposures that occurred from the 1940's through
the 1960's. The projects provide medical screening and
monitoring for former workers to identify those at high risk
for occupationally related diseases and to identify workers
with diseases that may be reduced in severity by timely
interventions.
In addition to its epidemiologic research and health
monitoring programs, EH has established the Comprehensive
Epidemiologic Data Resource, a growing archive of data sets
from the many epidemiologic studies sponsored by DOE. This
public archive provides the research community with data that
continue to be used to gain additional insights into the
relationships between occupational exposures and a variety of
health outcomes including diseases of aging like cancer.
Other Doe-Funded Research Related to Aging
Since the inception of the Atomic Energy Commission, the
Department and its predecessor agencies have carried out a
broad range of research and technology development activities
which have impacted health care and medical research. The
Medical Sciences Division within the Office of Biological and
Environmental Research, Office of Science, carries out a
Congressional mandate to develop beneficial applications of
nuclear and other energy related technologies, including
research on aging.
The Aging Research involves study of a brain chemical,
dopamine (DA), and its function in humans as they age. It has
long been recognized that age brings a significant decline in
the function of the brain DA system, but the functional
significance of this loss is not known. Medical imaging
studies, using radiotracers and positron emission tomography,
are designed to investigate the consequences of age-related
losses in brain DA activity in cerebral function and to
investigate mechanisms involved with the loss of DA function in
normal aging. The results of these studies to date have shown
that healthy volunteers with no evidence of neurological
dysfunction do experience a decline in parameters of DA
function, which are associated with a decline in performance of
motor and cognitive functions. The results of these studies
also indicate that changes in life style, such as exercise, may
be beneficial in promoting the health of the dopamine system in
the elderly.
ITEM 6--DEPARTMENT OF HEALTH AND HUMAN SERVICES
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ADMINISTRATION FOR CHILDREN AND FAMILIES
Title XX Social Service Block Grant Program
The major source of Federal funding for social services
programs in the States is Title XX of the Social Security Act,
the Social Services Block Grant (SSBG) program. The Omnibus
Budget Reconciliation Act of 1981 (Public Law 97-35) amended
Title XX to establish the SSBG program under which formula
grants are made directly to the 50 States, the District of
Columbia, and the eligible jurisdictions (Puerto Rico, Guam,
the Virgin Islands, American Samoa, and the Commonwealth of the
Northern Mariana Islands) for use in funding a variety of
social services best suited to the needs of individuals and
families residing within the State. Public Law 97-35 also
permits States to transfer up to ten (10) percent of their
block grant funds to other block grant programs for support of
health services, health promotions and disease prevention
activities, and low-income home energy assistance. In the
welfare reform legislation, Section 103 of Title I of Public
Law 104-193 gives states the authority to transfer up to 30
percent of their Temporary Assistance to Needy Families (TANF)
grant to SSBG and the Child Care Development Block Grant
programs. The Balanced Budget Act of 1997 (Public Law 105-33)
provided that the TANF transfer to SSBG would be up to 10
percent of a State's TANF grant. The Transportation Equity Act
of 1998 (Public Law 105-178) reduced the amount available for
transfer from TANF to SSBG to 4.25 percent beginning in Fiscal
Year 2001.
Under the SSBG, Federal funds are available without a
matching requirement. In fiscal year 2000, a total of $1.775
billion was allotted to States. Of that amount, $425 million
was delayed for funding until September 29, 2000. $1.909
billion was appropriated for these activities in fiscal year
1998. Within the specific limitations in the law, each State
has the flexibility to determine what services will be
provided, who is eligible to receive services, and how funds
are distributed among the various services within the State.
State and/or local Title XX agencies (i.e., county, city,
regional offices) may provide these services directly or
purchase them from qualified agencies and individuals.
A variety of social services directed at assisting aged
persons to obtain or maintain a maximum level of self-care and
independence may be provided under the SSBG. Such services
include, but are not limited to adult day care, adult foster
care, protective services, health-related services, homemaker
services, housing and home maintenance services,
transportation, preparation and delivery of meals, senior
centers, and other services that assist elderly persons to
remain in their own homes or in community living situations.
Services may also be offered which facilitate admission for
institutional care when other forms of care are not
appropriate. Under the SSBG, States are not required to submit
data that indicate the number of elderly recipients or the
amount of expenditures provided to support specific services
for the elderly. States are required, prior to the expenditures
of funds under the SSBG, to prepare a report on the intended
use of the funds including information on the type of
activities to be supported and the categories or
characteristics of individuals to be served. States also are
required to report annually on activities carried out under the
SSBG. Beginning with fiscal year 1989, the annual report must
include specific information on the numbers of children and
adults receiving services, the amount spent in providing each
service, the method by which services were provided, i.e.,
public or private agencies, and the criteria used in
determining eligibility for each service.
Based on an analysis of post-expenditure reports submitted
by the States for fiscal year 1998, the list below indicates
the number of States providing certain types of services to the
aged under the SSBG.
Services: Number of States \1\
Home-Based Services \2\............................. 36
Adult Protective Services........................... 31
Transportation Services............................. 19
Adult Day Care...................................... 25
Health Related Services............................. 14
Information and Referral............................ 16
Home Delivered...................................... 17
Congregate Meals.................................... 9
Adult Foster Care................................... 13
Housing............................................. 9
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\1\ Includes 50 States, the District of Columbia, and the five eligible
territories and insular areas.
\2\ Includes homemaker, chore, home health, companionship, and home
maintenance services.
In enabling the elderly to maintain independent living,
most States provide Home-Based Services which frequently
includes homemaker services, companion and/or chore services.
Homemaker services may include assisting with food shopping,
light housekeeping, and personal laundry. Companion services
can be personal aid to, and/or supervision of aged persons who
are unable to care for themselves without assistance. Chore
services frequently involve performing home maintenance tasks
and heavy housecleaning for the aged person who cannot perform
these tasks. States also provide Adult Protective Services to
persons generally sixty years of age and over. These services
may consist of the identification, receipt, and investigation
of complaints and reports of adult abuse. In addition, this
service may involve providing counseling and assistance to
stabilize a living arrangement. If appropriate, Adult
Protective Services may include the provision of, or arranging
for, home based care, day care, meal service, legal assistance,
and other activities to protect the elderly.
Low Income Home Energy Assistance Program
The Low Income Home Energy Assistance Program (LIHEAP) is a
Department of Health and Human Services block grant program
administered by the Office of Community Services (OCS) in the
Administration for Children and Families (ACF).
LIHEAP helps low-income households meet the cost of home
energy. The program is authorized by the Omnibus Budget
Reconciliation Act of 1981, as amended most recently by the
Community Opportunities, Accountability, and Training and
Educational Services Act of 1998, the NIH Revitalization Act of
1993 (P.L. 103-43), and the Human Services Amendments of 1994
(P.L. 103-252). In fiscal year 1999, all 50 states, the
District of Columbia, five territories, and 130 tribes and
tribal organizations received grants amounting to approximately
$1.2775 billion, including $175 million in emergency
contingency funds, and $2.2 million in re-allotted funds from
FY 1998.
In FY 2000, $1.1 billion is available. In addition, $300
million in emergency contingency funds are available if the
President decides to release some or all of the funds because
of weather, supply shortages, or other energy emergencies.
Federally-recognized and state-recognized Indian tribes,
including Alaska native villages, may apply for direct LIHEAP
funding. The amount to be reserved from a state's allotment for
a direct grant to a tribe will be based on the ratio of
eligible tribal households to total eligible households in the
state, or a larger allotment amount agreed on by the tribe and
state. Of the $1.1 billion appropriated for FY 2000, $27.5
million is earmarked for leveraging incentive awards, to reward
grantees that add non-Federal resources to help low income
households meet their home heating and cooling needs. Up to 25
percent of the leveraging incentive awards, or $6,875,000, will
be used to fund grants to LIHEAP grantees under the Residential
Energy Assistance Challenge Option Program (REACH) to develop
innovative programs to reduce the energy vulnerability of
LIHEAP-eligible households.
LIHEAP block grants are made to States, territories, and
eligible applicant Indian Tribes. Grantees may provide heating
assistance, cooling assistance, energy crisis interventions,
and low-cost residential weatherization or other energy-related
home repair to eligible households. Grantees can make payments
to households with incomes not exceeding the greater of 150
percent of the poverty level or 60 percent of the State's
median income.\3\ Most households in which one or more persons
are receiving benefits from the Temporary Assistance to Needy
Families (TANF) block grant, Supplemental Security Income, Food
Stamps or need-tested veterans' benefits, may be regarded as
categorically eligible for LIHEAP.
---------------------------------------------------------------------------
\3\ Beginning with fiscal year 1986, States are prohibited from
setting income eligibility levels lower than 110 percent of the poverty
level.
---------------------------------------------------------------------------
Low-income elderly households are a major target group for
energy assistance. They spend, on average, a greater portion of
their income for heating costs than other low-income
households. Grantees are required to target outreach activities
to elderly or handicapped households eligible for energy
assistance. In their crisis intervention programs, grantees
must provide physically infirm individuals the means to apply
for assistance without leaving their homes, or the means to
travel to sites where applications are accepted.
In fiscal year 1998, about 34 percent of households
receiving assistance with heating costs included at least one
person age 60 or over, as estimated by the March 1998 Current
Population Survey.
OCS is a member of the National Energy and Aging
Consortium, which focuses on helping older Americans cope with
the impact of high energy costs and related energy concerns.
The 1998 reauthorization retains legislation from the 1994
reauthorization that specifically allows grantees to target
funds to vulnerable populations, mentioning by name ``frail
older individuals'' and ``individual with disabilities''. No
new initiatives commenced in 1999 or 2000 that impacted on the
status of older Americans.
The Community Services Block Grant (CSBG) and the Elderly
I. Community Service Block Grant--The Community Service
Block Grant Act (Title VI, Subtitle B, Public Law 97-35 as
amended; and the Coats Human Services Reauthorization Act of
1998 105-285) is authorized through fiscal year 2003. The Act
authorizes the Secretary, through the Office of Community
Services (OCS), an office within the Administration for
Children and Families in the Department of Health and Human
Services, to make grants to States and Indian tribes or tribal
organizations. States and tribes have the authority and the
flexibility to make decisions about the kinds of local projects
to be supported by the State or tribe, using CSBG funds. The
purposes of the CSBG program are:
(A) to provide a range of services and activities
having a measurable and potentially major impact on
causes of poverty in the community or those areas of
the community where poverty is a particularly acute
problem.
(B) to provide activities designed to assist low
income participants including the elderly poor--
(i) to secure and retain meaningful
employment;
(ii) to attain an adequate education;
(iii) to make better use of available income;
(iv) to obtain and maintain adequate housing
and a suitable living environment;
(v) to obtain emergency assistance through
loans or grants to meet immediate and urgent
individual and family needs, including the need
for health services, nutritious food, housing,
and employment-related assistance;
(vi) to remove obstacles and solve problems
which block the achievement of self-
sufficiency;
(vii) to achieve greater participation in the
affairs of the community; and
(viii) to make more effective use of other
programs related to the purposes of the
subtitle,
(C) to provide on an emergency basis for the
provision of such supplies and services, nutritious
foodstuffs and related services, as may be necessary to
counteract conditions of starvation and malnutrition
among the poor;
(D) to coordinate and establish linkages between
governmental and other social services programs to
assure the effective delivery of such services to low-
income individuals; and
(E) to encourage the use of entities in the private
sector of the community in efforts to ameliorate
poverty in the community; (Reference Section 675(c)(1)
of Public Law 97-35, as amended).
It should be noted that although there is a specific
reference to ``elderly poor'' in (B) above, there is no
requirement that the States or tribes place emphasis on the
elderly or set aside funds to be specifically targeted on the
elderly. Neither the statute nor implementing regulations
include a requirement that grant recipients report on the kinds
of activities paid for from CSBG funds or the types of indigent
clients served. Hence, it is not possible for OCS to provide
complete information on the amount of CSBG funds spent on the
elderly, or the number elderly, or the numbers of elderly
persons served.
II. Major Activities or Research Projects Related to Older
Citizens in 1997 and 1998--The Human Services Reauthorization
Act of 1986 contained the following language: ``each such
evaluation shall include identifying the impact that assistance
. . . has on . . . the elderly poor.'' The reauthorization act
of 1998 requires that states assure a portion of the grant
funds will be used to support activities for elderly low-income
individuals as part of their State Application and Plan
submitted to OCS. Following the 1994 reauthorization, local
community action agencies began to include a description of how
linkages will be developed to fill identified gaps in services
through information, referral, case management, and follow-up
consultations as well as a description of outcome measures to
be used to monitor success in promoting self sufficiency,
family stability and community revitalization. As a result, the
CSBG Task Force on Monitoring and Assessment, a representative
body of eligible entities, established a goal which states,
``Low-income people, especially vulnerable populations, achieve
their potential by strengthening family and other support
systems''. This goal assists local, state and federal agencies
to focus jointly on vulnerable populations, particularly the
frail elderly.
III. Funding Levels--Funding levels under the CSBG program
for States and Indian Tribes or tribal organizations amounted
to $491.9 million in fiscal year 1999. For fiscal year 2000,
$521.5 million was appropriated. Of this amount, $3.3 million
is available for federally and state-recognized tribes. A total
of $8.4 million is available for training and technical
assistance.
Aging and Developmental Disabilities Program
CRITICAL AUDIENCES PROJECT
Grantee: Institute for the Study of Developmental
Disabilities, Indiana University
Project Director: Barbara Hawkins, Ph.D., (812) 855-6506;
Fax (812) 855-9630
Project Period: 7/97-6/30/2002; FY '97--$82,680
The project provides training in a late-life functional-
developmental model for audiences that are critical to
effective planning and care of older persons. Activities
include developing training modules and instructional videos
for interdisciplinary university credit courses, and
illustrating the model by demonstration projects in community
retirement settings.
CENTER ON AGING AND DEVELOPMENTAL DISABILITIES/CADD
Grantee: University of Miami/CADD, Miami, FL
Project Director: John Stokesberry, Ph.D., (305) 325-1043
Project Period: 7/97-6/30/2002; FY '97--$82,680
CADD is providing education and training to service
providers, parents and families; advocacy and outreach for
consumers, information to the public on aging and developmental
disabilities; networking, policy direction and community-based
research. Materials will include a manual for parents/
caregivers, a resource guide and a handbook on developing a
peer companion project.
INTERDISCIPLINARY TRAINING CENTER
Grantee: UAP--Institute for Human Development, University
of Missouri-Kansas City
Project Director: Gerald J. Cohen, J.D., M.P.A., (816) 235-
1770; Fax (816) 235-1762
Project Period: 7/97-6/30/2002; FY '97--$82,680.
The Center addresses personnel preparation needs with a
focus on administration, interdisciplinary training, exemplary
services, information/technical assistance/research; and
evaluation. Materials include training guide for aging,
infusion models, inservice fellowship curriculum, resource
bibliography, guide for training volunteers, and course
syllabus.
CONSORTIUM OF EDUCATIONAL RESOURCES
Grantee: UAP--University of Rochester Medical Center,
Rochester, NY
Project Director: Jenny C. Overeynder, ACSW, (716) 275-
2986; Fax (716) 256-2009
Project Period: 7/97-6/30/2002; FY '97--$82,680.
An inter-university interdisciplinary consortium of
educational resources in gerontology and developmental
disabilities is being established in western New York, to be
linked to local and state networks. The project will develop
and implement preservice and inservice education curriculum for
direct care and nursing home staff.
COMMUNITY MEMBERSHIP THROUGH PERSON-CENTERED PLANNING
Grantee: Eunice Kennedy Shriver Center, Inc. Shriver Center
UAP
Project Director: Karen E. Gould, Ph.D., (617) 642-0238
Project Period: 7/92-6/30/1999; FY '97--$82,680
The Center has two primary goals which are: 1) to implement
a service delivery model that creates a new vision for
individuals who are labeled ``old'' and ``developmentally
disabled'' in Massachusetts, one in which entry into valued
adult roles is expected and capacities and interests form the
basis for structuring support; and 2) to provide training to
persons with developmental disabilities, family members and
friends, graduate students, professionals and community members
so that they can develop the skills necessary to support
community entry and inclusion in valued roles and relationships
for older adults with developmental disabilities, and learn to
use these skills in other settings.
NORTH DAKOTA PROJECT FOR OLDER PERSONS WITH DEVELOPMENTAL DISABILITIES
Grantee: North Dakota Center for Disabilities, Minot State
University
Project Director: Dr. Rita Curl and Dr. Demetrios
Vassiliou, (701) 857-3580
Project Period: 7/97-6/30/2002; FY '97--$82,680
The project seeks to upgrade the training opportunities
available to North Dakotans; 1) project staff works with pre-
service geriatric programs to develop strong DD components; 2)
project staff expands on an existing inservice training program
to provide information on aging DD service provision; and 3)
the project supports the development of training opportunities
for secondary consumers and advocates.
INTERDISCIPLINARY TRAINING INITIATIVE ON AGING AND DEVELOPMENTAL
DISABILITIES
Grantee: Graduate School of Public Health, University of
Puerto Rico - Medical Sciences
Project Director: Dr. Margarita Miranda, (809) 758-2525,
ext. 1453, (809) 754-4377
Project Period: 7/97-6/30/2002; FY '97-$82,680
The project provides pre-service training including
practical experience on best practices in serving the older
population with developmental disabilities to three (3)
graduate and to three (3) undergraduate students from different
disciplines per year (from the second funding year on);
provides culturally adapted in-service training to the Catano
Family Health Center's interdisciplinary team and to at least
40 professionals in the aging service per year through the
Graduate School and implementation of five regional Seminars on
Aging and Developmental Disabilities throughout Puerto Rico.
CREATIVE CHOICES FOR HEALTHY LIVING
Grantee: University-Affiliated Program Department of
Pediatrics, Univ. of Arkansas for Medical Sciences.
Project Director: Judith Holt, Ph.D ((501) 682-9900
Project Period: 7-97-6/30/2002, FY '97--$82,680
The UAP of Arkansas' Training Initiative Project, Creative
Choices for Healthy Living, will focus on persons who are aging
with developmental disabilities, their access to appropriate
services and supports within the community. Specifically, it
will enhance the health and well-being of older persons with
developmental disabilities and other members of the aging
community; enhance the skill and competencies of community
trainers to provide the training identified by the community
action plan; expand the project into new communities; develop
and disseminate preserve training modules for undergraduate and
graduate courses; disseminate project training modules for use
in other settings state- and nation-wide; and evaluate the
project's effects.
MEETING THE NEEDS OF A CULTURALLY-DIVERSE POPULATION
Grantee: Department of Pediatrics, Children's Hospital Los
Angeles
Project Director: Irma Castaneda, Ph.D (213) 669-2300-9900
Project Period: 7/1/97-6/30/2002, FY '97--$82,680
Develop and implement an interdisciplinary training program
with a special emphasis on the multicultural aspects of aging
and developmental disabilities which is integrated into
Department's curriculum for a minimum of one primary or
secondary consumer, and two graduate students per year. Will
integrate material on multicultural aging and developmental
disabilities into existing gerontology certificate programs.
Provide training and consultation on the integration of content
related to multicultural aging and developmental disabilities
to four university departments. Provide training to a total of
100 health care providers, community support personnel, and
family members on the changing health and social needs of aging
individuals with developmental disabilities from ethnic
minority groups.
ADMINISTRATION ON AGING
Section I.
1. Reauthorization
On November 13, 2000, President Clinton signed into law
legislation (P.L. 106-501) to reauthorize the Older Americans
Act. The amended Act, last reauthorized in 1992, will provide
essential home and community-based services to millions of
older Americans across the United States. In addition, for the
first time ever, it will provide under the National Family
Caregiver Support Program much needed support to families who
are caring for their loved ones who are ill or who have
disabilities.
2. National Family Caregiver Support Program
In 1999, President Clinton announced the Administration on
Aging proposal to create the National Family Caregiver Support
Program (NFCSP). The NFCSP is one of four LTC initiatives
proposed in the FY 2000 Administration budget to help families
sustain their efforts to care for an older relative who has
serious chronic illness or disability. Under this Older
Americans Act program, State Units or Offices on Aging, working
in partnership with local Area Agencies on Aging, community
service providers, and consumer organizations, will be expected
to put in place at least five program components:
Individualized information on available
resources to support caregivers;
Assistance to families in locating services
from a variety of private and voluntary agencies;
Caregiver counseling, training, and peer
support to help them better cope with the emotional and
physical stress of dealing with the disabling effects
of a family member's chronic condition;
Respite care provided in the home, at an
adult day care center, or over a weekend in a nursing
home or residential setting such as an assisted living
facility; and
Limited supplemental services to fill a
service gap that cannot be filled in any other manner.
The NFSCP program was enacted as part of the Older
Americans Act Amendments of 2000 (P.L. 106-501) signed into law
on November 13, 2000. Full start-up funding for the program, as
proposed at $125 million, has been provided for FY 2001.
The basis underlying the program is simple: family
caregivers need help. Families, not social service agencies or
government programs, are the mainstay underpinning long term
care (LTC) for older persons in the United States. According to
the most recent National Long Term Care Survey (1994), more
than seven million persons are informal caregivers providing
unpaid help to older persons who live in the community and have
at least one limitation in their activities of daily living.
These caregivers include spouses, adult children, and other
relatives and friends. Of the older persons receiving paid and
unpaid assistance, 95 percent have family and friends involved
in their care. Paid home care is the exception, not the rule,
for the great majority of older persons with disabilities.
The degree of caregiver involvement has remained fairly
constant for more than a decade, bearing witness to the
remarkable resilience of the American family in taking care of
its older persons. This is despite increased geographic
separation, greater numbers of women in the workforce, and
other changes in family life. Thus, family caregiving has been
a blessing in many respects. It has been a budget-saver to
governments faced annually with the challenge of covering the
health and LTC expenses of persons who are ill and have chronic
disabilities. If the work of caregivers had to be replaced by
paid home care staff, the estimated cost would be $45-95
billion per year.
3. Longevity Symposium
The 21st century presents many opportunities and challenges
for the Aging Network--medical and technological advances, home
and community-based care options, the need to prepare for a
long life, and the need to implement evidence-based and
culturally-responsive services to ensure that American elders
receive the most effective assistance. The Administration on
Aging convened a symposia series which highlighted the agency's
commitment to helping the Aging Network prepare for the myriad
of issues that come along with the gift of longevity.
The first symposium, Longevity in the New American Century,
convened in March 1999, was designed to identify the most
potent, most promising research findings on issues important to
older Americans and their families. Based upon these research
findings, the Administration on Aging and other agencies and
organizations will be able to make strategic decisions and
build outcome-oriented programs for older Americans. The
speakers invited to share information at this symposium were
asked to provide specific ideas for an evidence-based, outcomes
agenda in relation to the issues of caregiving, information and
technology, diversity, consumer protection, economic security,
and health.
The second symposium, Building the Network on Aging
Toolkit, convened in May 2000, focused on the presentation of
evidence-based, outcomes-oriented strategies that can directly
be used to develop and strengthen policies, programs and
services. The primary purpose of this second symposium was to
bridge the gap between research and practice. The speakers
presented tools and methods that are essential components of
programs for family caregiver support, cultural competent
service delivery, the elimination of health disparities, life
course planning, the application of new technologies, and for
the measurement of program outcomes.
4. Priority Initiatives
Cultural Competence
The Administration on Aging (AoA) recognizes that minority
Americans often are at greater risk of poor health, social
isolation, and poverty. Currently, minority elders comprise
over 16.1 percent of all older Americans (65 years of age and
older). In the future, this number is expected to increase
dramatically. As a result, AoA has focused on educating the
public and the aging network on cultural competence.
Cultural competence is a set of congruent behaviors,
attitudes, knowledge, and policies that come together in a
practice and a service system that enables professionals to
serve diverse clients. During calendar years 1999 and 2000, AoA
has initiated the following activities to increase culturally
competent practice:
AoA's Longevity Symposia series, entitled
Longevity in the New American Century included a few
workshops focusing on cultural competence and the
minority aging experience. Included in the workshops
were new research, policy development ideas, and
suggestions for programs that promote equality in the
aging experience for minority elders;
Collaboration with the Office of Minority
Health (OMH) on the May 2000 edition of Closing the
Gap, which focused on health issues and concerns for
minority older Americans;
A Guide for Culturally Competent Practice
was developed for dissemination to providers of aging
services;
Grants for applied research and
demonstration projects seeking to provide culturally
and linguistically competent services to Alzheimer's
Disease patients and their families in New York City,
Los Angeles, and San Francisco;
Grants for a legal services hotline project
serving northern California;
Grants for a resource center that
disseminates educational and best practice materials to
better equip minority and non-English speaking
consumers to combat waste and fraud in the Medicare and
Medicaid programs;
Presentations by AoA staff at national
conferences and meetings on how to develop culturally
appropriate services to serve minority elders;
AoA's website addition ``The Many Faces of
Aging: Resources to Effectively Serve Minority Older
Persons'' provides information on cultural competence.
Eldertech--Technologies for Successful Aging:
The number of older persons in the U.S. is estimated to
increase from over 33 million today to 53 million in 2020. By
2030, the demographic profile for the whole nation will be
similar to the profile in the state of Florida today.
Technologies that help to meet the challenges of aging, both
for individual Americans as well as for the entire nation, will
be increasingly valuable as the shift in demographics continue
this century.
In October 2000, the White House Office of Science and
Technology Policy held a Forum on Technologies for Successful
Aging. The Administration on Aging, as part of the cross-
Cabinet Steering Committee for this forum, played a key role in
developing the agenda for the forum whose goal was to identify
collaborative, technology transfer, and technology development
and deployment opportunities for government, industry and
academic communities that help to improve the independence,
mobility, security, and health of aging Americans.
In support of this goal, the 100 participants of the
Conference began work to identify current and prospective
barriers to those opportunities, mechanisms of support, and
areas where additional research is needed. Specific topic areas
included Health care and Assistive Devices, Regulatory and
Technology transfer, Information and Technology, Mobility,
Housing and the Workplace, and Consumer Protection, Security
and Privacy issues. The Forum's overarching mission was to
identify and prioritize recommendations that can be articulated
as a set of near-term opportunities as well as long-term
challenges to federal policymakers. The Intergovernmental
Steering Committee continues to meet to follow up and formalize
the steps that need to be taken in the coming months and years,
and recommendations will be made to the incoming Administration
to continue the work that has begun.
Mental Health Initiatives
Companion Report to Surgeon General's Report on Mental
Health
AoA has authored a report that expands on the discussion of
older adults and mental health contained in the 1999 Surgeon
General's report. The AoA report focuses on challenges in the
delivery of mental health services to older Americans, and
highlights a number of supportive services that can provide
vital assistance to older adults with mental health problems
and their families. Release of this report is planned for
January 2001.
The report includes background information about the
demographic characteristics of older Americans, the common
stressors and adaptations that older persons face, and a brief
summary of the findings from the Surgeon General's report. The
report describes community mental health services, delivery of
mental health services in primary and long-term care, and
Medicare and Medicaid financing of mental health care.
Supportive services discussed in the report include respite
care, adult day services, support groups and peer counseling
programs, wellness and health promotion programs, mental health
outreach services, and caregiver programs. The discussion of
each service includes its purpose, implementation models and
examples, and research regarding effectiveness.
Lastly, the report sets forth the challenges that must be
addressed in order to provide effective community-based care to
older persons with mental illnesses. Identified needs include:
expanding prevention and early intervention services;
increasing the number of professionals and paraprofessionals
trained in geriatric mental health; providing adequate
financing for mental health services; enhancing collaboration
among delivery systems; improving access to mental health care;
educating the public about mental illness and mental health
treatment; expanding research on mental health issues in older
adults; addressing the mental health needs of special
populations; and encouraging consumer involvement.
Alzheimer's Disease Demonstration Grants to States
The Alzheimer's Disease Demonstration Grants to States
Program (ADDGS) was established under Section 398 of the Public
Health Service Act (P.L. 78-410) as amended by Public Law 101-
157 and by Public Law 105-379, the Health Professions Education
Partnerships Act of 1998. Beginning in fiscal year (FY) 1999,
the program was transferred within the Department of Health and
Human Services from the Health Resources and Services
Administration (HRSA) to the Administration on Aging (AoA).
The ADDGS program's mission is to expand the availability
of diagnostic and support services for persons with Alzheimer's
disease, their families, and their caregivers. The
Administration on Aging provides an added focus of reaching
hard-to-serve and underserved people with Alzheimer's disease
or related disorders (ADRDs).
In general, the ADDGS projects demonstrate how existing
public and private resources within States may be more
effectively identified, utilized, and coordinated to enhance
the educational and service delivery systems for persons with
Alzheimer's disease, their families and caregivers. Under the
Program, state grantees:
Link public and non-profit agencies that develop and
operate respite care, and other support, educational, and
diagnostic services within the State to people who need
services;
Deliver services such as primary health care physician
education and support services including respite care, home
health care, personal care, day care, companion services,
short-term respite care, and other forms of respite and
supportive services to persons with ADRDs (at least 50 percent
of the total grant must be spent on these activities);
Improve access to home and community-based long-term care
services for persons with Alzheimer's disease & their families;
Provide individualized and public information, education,
and referrals about 1) diagnostic, treatment and related
services that are available; 2) sources of assistance to obtain
such services, including entitlement programs; 3) legal rights
of individuals and families affected by ADRD.
In FY2000, AoA held a competitive grant award process,
resulting in the issuance of grants to 16 states. Each grant
has a 3-year project period and requires local match in the
amounts of 25 percent (year 1), 35 percent (year 2), and 45
percent (year 3). The general programmatic foci of the program
are to:
develop models of care for persons with
Alzheimer's disease, and
improve the responsiveness of the home and
community based care system for persons with dementia.
Projects are targeted to hard-to-reach populations
including ethnic minorities, low income and rural families with
Alzheimer's disease. The 16 states with ADDGS grants are
Alaska, Arizona, Arkansas, California, Iowa, Maine, Minnesota,
Nebraska, Nevada, New Hampshire, New Mexico, Rhode Island,
Texas, Vermont, Virginia, and Wisconsin.
Managed Care Initiative
In addition to the 16 new projects, 5 states have grants of
$80,000 to fund services provided under the ADDGS Managed Care
Initiative, an effort started in 1997 by HRSA. The Managed Care
Initiative is designed to test the impact of community-based
service interventions on primary care physician utilization
rates by persons with Alzheimer's disease in a managed care
environment.
Organizations with FY 2000 ADDGS Managed Care Initiative
Grants are:
DC Office on Aging
Florida Department of Elder Affairs
Michigan Department of Community Health
Ohio Department on Aging
Oregon Senior and Disabled Services Division
5. Reinventing the Administration on Aging
Performance Measurement
AoA and the Aging Network have forged a partnership to
utilize the tools provided by the Government Performance and
Results Act (GPRA) to demonstrate to the Congress and the
public the value of the programs administered under the Older
Americans Act (OAA). GPRA has provided the Network the
opportunity to use performance measurement to continuously
document the results that service providers, Area agencies on
Aging, State agencies on Aging, and AoA produce for older
Americans. The reauthorized Older Americans Act reinforces the
importance of measuring results, and directs AoA to develop
performance outcome measures for Older Americans Act programs
by December 2001. AoA and the Network have launched the
Performance Outcomes Measures Project (POMP) to serve as a
mechanism to identify and institutionalize indicators of
results that will serve the long-term program improvement needs
of the Network and Older Americans Act programs.
Early in its second year of operation, the POMP is building
on the consensus achieved by AoA's initiative to pull together
selected network participants to identify a set of core areas
and methods of performance measurement that can serve the aging
community. With the assistance of accomplished researchers in
the fields of gerontology and statistics, State and area
partners from 16 States developed and tested performance
measurement instruments that center on the needs and
characteristics of the people they serve. Consistent with the
best quality management practices in the field, POMP focuses
primarily on customer assessment measures for core service
areas, such as home care, transportation, and caregiver
services. Pilot test users have found a high degree of
satisfaction with services, and have also identified customer-
based recommendations for service improvement. For example,
test findings for pilot areas indicate that transportation
services are used most for doctor's appointments, and that
expanded hours of service would be the most helpful change.
State and area partners also tested nutrition assessment
instruments for new clients and found that the nutritional risk
of these individuals was very high. This indicates for test
locations that nutrition services are targeted to the elderly
who need the service most. Follow-up surveys of these same
individuals will provide an indicator of the effects of Aging
Network nutrition services on the nutritional status of these
high-risk individuals after six months of program
participation.
Statistical methodologies that are useful to program
administrators in the field are an added and promising feature
of the AoA sponsored performance outcome measurement effort.
The POMP survey methods and instruments have been designed to
allow real people, working area agency staff and others, to
conduct valid sample surveys of clients across an assortment of
service areas. The materials and experiences of pilot agencies
are being documented and have been proven to be replicable for
a variety of agencies and programs.
To support and enhance the indicators of program results
that the performance outcome measurement partners are working
to define, AoA is making use of ongoing administrative data to
more fully illustrate and define the success of the Network in
the service of elderly Americans. Ongoing administrative data
from State and area agencies will be useful for demonstrating
the effectiveness of these program entities in targeting
services to those most vulnerable and in need. Existing
administrative data will be useful for demonstrating the
effectiveness of the Network in coordinating services and
leveraging resources in support of the program objectives of
the Older Americans Act.
AoA and its program partners are committed to use
performance measures to inform decision making that improves
programs for older Americans. As AoA's performance measures
mature, and trends in program performance emerge, AoA and the
Network believe that these indicators of results, along with
program evaluation and other management assessment tools, will
be critical to program development in support of older
Americans.
Policy Analysis
For the first 30 years after enactment of the Older
Americans Act (OAA) the major thrust of efforts undertaken by
the Administration on Aging (AoA) was to support the
development of a nationwide infrastructure with a capability to
promote more comprehensive and coordinated home and community-
based services to vulnerable older individuals. A network of
State and Area Agencies on Aging, as well as providers of
supportive and nutrition services, has developed which
leverages other sources of funds and coordinates with other
agencies in addressing the needs of older individuals in
greatest economic or social need, including older individuals
with physical or mental impairments, living alone, with low
income, minority status, or rural residence. The statutory
basis for these efforts may be found in Titles III, VI, and VII
of the OAA.
More recently the focus has shifted to the responsibilities
of the AoA to ``serve as the effective and visible advocate for
older individuals within the Department of Health and Human
Services and with other departments, agencies, and
instrumentalities of the Federal Government by maintaining
active review and commenting responsibilities over all Federal
policies affecting older individuals'' (OAA Section 202(a)(1)).
The OAA requires that the Assistant Secretary for Aging ``shall
coordinate, advise, consult with, and cooperate with the head
of each department, agency, or instrumentality of the Federal
Government proposing or administering programs or services
substantially related to the objectives of this Act, with
respect to such programs or services'' (OAA Section 203(a)(1)).
Additionally the OAA provides that ``The head of each
department, agency, or instrumentality of the Federal
Government proposing to establish programs and services
substantially related to the objectives of this Act shall
consult with the Assistant Secretary prior to the establishment
of such programs and services.'' (OAA Section 203(a)(2)).
To implement these statutory requirements, recently a
policy unit has been established in areas defined in the
Declaration of Objectives for Older Americans (OAA Section 101
(1) ``An adequate income...''.), (2) ``The best possible
physical and mental health.....''), (3) ``Obtaining and
maintaining suitable housing......''). In the Economic Security
policy area there will be review and analysis of legislation
and regulations covering programs administered by the Social
Security Administration, the U.S. Department of Labor, and
other agencies; in the Housing policy area of programs
administered by the U.S. Department of Housing and Urban
Development and other agencies; in the Health policy area of
programs administered by the Health Care Financing
Administration, the Veterans Administration, the Substance
Abuse and Mental Health Services Administration and other
agencies. The policy analysts represent AoA at meetings with
representatives of these departments and agencies and
participate actively on work groups. They prepare analyses of
reports, develop policy briefs, and advise senior officials on
developments in their policy areas.
International Activities
The AoA responds to requests for information from
international organizations such as the United Nations, foreign
governments, and agencies. It hosts international scholars,
officials and practitioners who come to the U. S. to learn
firsthand about America's response to population aging. In 1999
and 2000, AoA staff briefed delegations from over 25 countries.
The AoA participates in a number of collaborative efforts
with other countries and with international organizations, such
as the World Health Organization, to enhance aging programs and
policies worldwide. The AoA has a signed agreement with the
China National Committee on Aging of the People's Republic of
China to share information and to develop collaborative
activities.
The Aging Core Group of the Health Working Group, U.S.-
Mexico Binational Commission.--The Commission promotes
exchanges at the Cabinet level on a wide range of issues
critical to U.S.-Mexico relations. The Aging Core Group is one
of five areas of collaboration between the U.S. Department of
Health and Human Services and the Mexican Ministry of Health.
The U.S. side of the Core Group is led by the Assistant
Secretary for Aging. A number of on-going exchanges of
information, training and technical assistance have taken place
to help both countries better address the special health needs
of older people. In 1999 and 2000, in collaboration with the
AoA, the Mexican Ministry of Health hosted invitational
conferences to share models of care for the elderly; nutrition
and the elderly; and prevention and control of chronic disease
in the elderly.
The International Year of Older Persons 1999.--The AoA
coordinated the U.S. government's activities for the
International Year of Older Persons (IYOP). A Federal Committee
for the IYOP (the ``Committee'') was created and chaired by the
Assistant Secretary for Aging. The Committee consisted of over
40 governmental agencies and departments.
The IYOP was formally launched by the reading of a message
from President Clinton by HHS Secretary Donna E. Shalala on
October 19, 1999, at a gathering at the U.S. Department of
Agriculture. Guests included Cabinet heads and representatives,
international delegates and senior advocates in Washington,
D.C. A special video message was delivered from US Senator John
Glenn (D-OH) upon his return to space on October 29 as a NASA
researcher. Gubernatorial proclamations of the IYOP within
their states were displayed.
In June 1999, the AoA and the Committee
convened the invitational symposium Coming of Age:
Federal Agencies and the Longevity Revolution. The
symposium brought together some 300 senior
administrators from across the Executive Branch to
examine and address the policy and program implications
of our rapidly aging American society. The goal of the
symposium was to establish a foundation for the
advancement of the federal policy and program agenda
related to older Americans and their families in the
21st century. Discussions were organized around the
major themes of economic security, aging in place,
older people as a resource, health promotion and care,
and disability and long-term care.
An IYOP website was established on the AoA
home page and became a major international source of
information on the IYOP.
The IYOP culminated with an event entitled
``Positive Aging: A Goal for the Next Millennium''--A
Day Celebrating the Culmination of The United Nations
International Year of Older Persons. The event was
hosted by the Committee and the US Committee
(representing non-governmental aging associations). The
program included a federal and a business panel and an
award ceremony for communities that have celebrated the
IYOP.
The Federal Committee on Aging Issues.--With the close of
the IYOP, the Committee continues its work as the Federal
Committee on Aging Issues. The Assistant Secretary for Aging
continues to chair the Committee. The Committee continues to
share information among members and to examine ways of
implementing recommendations from the 1999 symposium, Coming of
Age: Federal Agencies and the Longevity Revolution.
International Plan of Action on Aging, 2nd World Assembly
on Aging.--Working together with the Committee, AoA is
coordinating the federal government's input to the revised
International Plan of Action. The revised Plan will be
presented for discussion at the 2nd World Assembly on Aging, to
be held under the UN auspices in 2002.
International Conference on Rural Aging.--Under Title IV of
the Older Americans Act, the Administration on Aging funded
West Virginia University to put on the first international
conference on rural aging: Rural Aging: A Global Challenge. The
West Virginia University Center on Aging is now a UN Programme
on Aging Advisory Site on Rural Aging. Representatives of 40
nations attended the five-day conference held in June 2000 in
Charleston, West Virginia. Policy recommendations on worldwide
rural aging were adopted. They will become the basis of a Rural
Aging Plan of Action to be included in the revised UN
International Plan of Action on Aging.
Work Force Plan of the Administration on Aging
AoA's workforce planning initiative was completed here at
headquarters in December, 1999 and in our regional offices in
November, 2000. The plan highlights the Administration on
Aging's vision of itself to be actualized by the year 2005,
identifies competencies of its present workforce and areas for
staff development, and focuses on organizational competency
gaps to be addressed in the recruitment of staff in the future.
In the last few months AoA has recruited approximately
twenty new employees, following the indicators, conclusions,
and recommendations contained in our workforce plan, and we
will continue to use the workforce plan as the basis for our
recruitment and staff development efforts in the future. The
workforce plan indicates that the agency's present allocation
of staff to the organizations support functions or
infrastructures (i.e. grants, budget and finance, personnel,
and training, IRM, and general administrative functions) are
adequate for the size of the agency. The staffs performing
these functions also are younger, with less seniority within
the agency, and tend to have received technical training
specific to their particular jobs. On the other hand AoA's
workforce plan highlights the fact that an overwhelming number
of the almost one hundred employees the agency has lost since
1993 have been program staff. That trend will continue unabated
over the next five years, when a 60 percent turnover in staff
is anticipated because of retirements.
AoA has recently filled a vacant management position which
oversees our regional operations and a planning and evaluation
officer position, but the vast majority of the new recruits are
policy analysts and program analysts with extensive experience
in applying research methodologies, evidence-based principles
and qualitative and quantitative approaches to policy
formulation and development and to the design, implementation,
and evaluation of programs and services. AoA has recruited
policy analysts with a thorough, in-depth knowledge of the
following public policy areas, as they relate to older people:
home and community based long term care, healthcare, housing,
economic security, and mental health. The newly hired program
analysts will concentrate on program design, technical
assistance, and implementation in the following program areas:
home and community based long term care/housing, elder rights/
legal services, public health promotion, and consumer
protection.
A few of these analysts have been assigned the task of
serving as mentors to the two Presidential Management Interns
(PMI) recruited by the agency this summer. Next year and in
subsequent years, AoA will be in a position to concentrate on
recruitment of staff at the GS 9 entry level of the PMI
program, the Outstanding Student program, and the Student Co-op
program and anticipate being able to employ each year at least
four to six staff from these programs to replace program staff
retiring.
Regional Teams
As part of the new vision for the Administration on Aging,
The Assistant Secretary on Aging directed the Regional Offices
in 1999 to establish teams, including multi-regional teams, to
help advance AoA's priorities in the areas of public/private
partnerships, diversity, customer service and financial
management. The teams made significant progress during 1999 and
2000.
The Boston (Region I) and New York (Region II) Offices
worked together on a team to foster public/private
partnerships. As it's first project, the team established a
partnership with the Federal Deposit Insurance Corporation
(FDIC) and the Women's Institute for a Secure Retirement
(WISER) to help mid-life and elderly women, especially low-
income and minorities, understand and prepare to meet their
everyday economic and financial needs at progressive states of
aging. The partnership has produced a financial literacy
program known as Power 2000 Take Control of Your Financial
Future. The program includes a training manual with a suggested
curriculum, materials that can be duplicated, resource guides
and information on how to conduct a local workshop. To promote
the program, AoA, FDIC and WISER identify and stimulate
opportunities for presentations to the Aging Network, the
banking network and other community-based groups, all of whom
are asked to serve as catalysts in promoting the financial
literacy program in their localities. Local partnerships are
then formed among the partners and other federal, state and
local organizations to serve as facilitators, resources and/or
faculty in conducting Power 2000 presentations locally. The
program was successfully piloted during 2000 in New York City
and in one rural community in Upstate New York. Based on the
results of the pilot, the partnership plans to roll out the
program in 2001 to AoA regions nationwide.
The San Francisco Office (Region IX) team is focused on
policy issues related to diversity and aging. The team has
developed a new section of the AoA web site, www.aoa.gov, ``The
Many Faces of Aging: Resources to Effectively Serve Minority
Older Persons,'' to help increase access to programs and
services for older minority Americans and their caregivers. The
site was launched in December, 2000 and includes a range of
health and aging resources for and about minorities and diverse
aging populations; demographic snapshots and statistics; and
laws and executive orders related to ensuring improved access
and culturally appropriate services. The site highlights
various approaches to develop culturally and linguistically
responsive services for minority older persons. The Dallas-
Atlanta (Regions IV and VI) team has been building a diversity
website that will offer state-specific data on minority
populations. These two initiatives were developed response to
the growing diversity of the aging population. Currently,
minority elders comprise over 16.1 percent of all older
Americans (65 years of age and older). In the future, their
numbers are expected to increase dramatically. Between 1999 and
2030, the older minority population 65+ is projected to
increase by 217 percent, compared with 81 percent for older
white population.
The Denver Office (Region VIII) team is focused on customer
service, including the establishment of internal performance
outcome measures for employee participation and performance.
The Denver team has developed a comprehensive orientation
manual for all new AoA employees. The manual provides
background information on the Department of Health and Human
Services, AoA, the Older Americans Act and the Aging Network,
as well as information on internal operating policies and
procedures. The manual will be issued in January 2001.
The Denver team also has developed several tools for AoA's
external customers. The ``Compendium of Grant Resources for
Native American Elders Programs'' was developed in partnership
with the Community Resource Center in Denver and the National
Committee to Preserve Social Security and Medicare. The
Compendium contains resources on funding, publications,
resource agencies, profiles of funders and internet resources
targeted to Native Americans. The Compendium project was
initiated in Region VIII when Tribal Elders Programs requested
additional funding information from the regional office to
augment moneys received under Titles VI and III of the Older
Americans Act. ``Cyberspace Resources on Retirement'' is a
publication that identifies internet links on retirement and
financial planning, health, quality of life and other baby
boomer issues. The publication was a result of a creative
partnership among the Develop Denver Office, the Community
College of Denver, American Association for Retired Persons,
and the National Committee to Preserve Social Security and
Medicare.
The Chicago (Region V) and Kansas City (Region VII) Offices
have collaborated on establishing a fiscal management team
comprised of representatives from all the regional offices and
the AoA central office in Washington. The team serves as the
focal point within AoA on all grantee related fiscal matters.
The team ensures the provision of timely, consistent, uniform
and accurate fiscal policy and technical assistance to the
state units on aging, Native American programs, and the area
agencies on aging. During 2000, the team developed a manual for
AoA project officers, and drafted several technical assistance
documents that will be used to implement the 2000 Amendments to
the Older Americans Act, including the National Family
Caregiver Support Program.
The Seattle (Region X) Office team is looking at the issue
of active aging, including the opportunities and challenges
associated with creating meaningful roles for older people.
There is a growing body of research which suggests that both
the individual and the nation as a whole can benefit from older
people being actively engaged in activities which allow them to
make meaningful contributions to their families, their
communities and the larger society. This issue will take on
great significance as the baby boom generation ages. As a first
step in exploring this issue, the Seattle team is reviewing the
literature to identify what we know about the key factors and
dynamics associated with active aging.
Section II
1. Summary of Reports
State Program Report
Each year, the Administration on Aging (AoA) awards Older
Americans Act (OAA) funds to every state based primarily on the
relative size of the state's elderly population.
Each State Unit on Aging (SUA), in turn, relies upon Area
Agencies on Aging (AAAs)to partner with a diverse set of home
and community service providers in getting supportive,
nutrition, and related services to older persons. (Several
states with relatively small populations combine the SUA and
AAA functions into a single agency). The following is summary
information on the clients, services, expenditures and staffing
of OAA programs for fiscal year 1998 (most recent data
available).
Clients
Older Americans Act programs served nearly 6.5 million
persons 60 years of age and older in FY 1998. While services
are open to all older Americans, efforts are made to focus on
those with the greatest economic and social need. Thus, OAA
program participants have incomes below the poverty level at a
rate nearly four times that of the total population in this age
group. Nearly one-third of these individuals live in rural
areas, compared to less than one-quarter of the total
population age 60 and above. Participants in OAA service
programs were members of racial or ethnic minority groups at a
level nearly one-third higher than the total elderly
population. OAA minority clients had incomes below the poverty
level at a rate more than twice that of the minority elderly
population overall.
Services
Older Americans Act programs provided nearly 20 million
units of personal care, homemaker and chore services in FY
1998. During the same period, OAA programs provided almost 130
million home delivered meals and 114 million congregate meals.
Older persons received over 45.7 million trips to medical
services, grocery stores, and other community services through
OAA transportation programs. Over 13 million units of
information and assistance services were provided to older
persons and those acting on their behalf.
Expenditures and Staffing
State Units on Aging and Area Agencies on Aging generated
nearly $2 billion in state and local funds to supplement the
$678 million in OAA dollars they received from AoA in FY 1998.
Many SUAs also administered other programs for the elderly such
as Medicaid home and community based waivers and state funded
support services. There were 3,285 SUA staff and another 37,174
staff at the AAA level working together to administer the much
needed services provided through OAA funds. These figures
include over 16,000 volunteers.
Ombudsman Program Report
State Long Term Care Ombudsmen are advocates for residents
of nursing homes, board and care homes, assisted living
facilities and similar adult care facilities. They work to
resolve problems of individual residents and to bring about
changes at the local, state and national levels to improve
care. While most residents receive good care in long-term care
facilities, far too many are neglected, and other unfortunate
incidents of psychological, physical and other kinds of abuse
do occur. Thus, thousands of trained volunteer ombudsmen
regularly visit long-term care facilities, monitor conditions
and care, and provide a voice for those unable to speak for
themselves.
Begun in 1972 as a demonstration program, the Ombudsman
Program today is established in all states under the Older
Americans Act, which is administered by the Administration on
Aging (AoA). Local ombudsmen work on behalf of residents in
hundreds of communities throughout the country. Detailed
information on the program for 1998 (the latest year for which
reports are available) follows.
Cases and Complaints
In FY 1998, ombudsmen nationwide opened 136,424 cases and
closed 121,686 cases involving 201,053 individual complaints,
most of which were filed by residents or friends and relatives
of residents. Eighty-two percent of cases were in nursing home
settings; 17 percent involved board and care, assisted living
and similar facilities; and one percent were in non-facility
settings. The top five nursing home complaints were in
categories involving poor resident care, lack of respect for
residents and physical abuse. Seventy-two percent of nursing
home complaints and 67 percent of board and care complaints
were resolved or partially resolved to the resident's or
complainant's satisfaction.
Program Funding
FY 1998 program funding totaled $47,404,557, $4.35 million
more than in FY 1997. While program funding rose in FY 1998, it
was relatively level for the period FY 1995 to 1998. Resources
are still inadequate to meet the need for ombudsman services
and volunteer coverage in all facilities covered by the
program. About 58 percent of the program funding was from
federal sources, especially Title III of the OAA; states
provided about 28 percent of funding; 14 percent was from
private sources.
Local Programs, Staffing and Volunteers
There were 587 local and regional ombudsman programs in FY
1998, essentially the same as in FY 1997; most of these
programs were located in area agencies on aging. The number of
paid ombudsman staff increased from 887 full-time equivalents
(FTEs) in FY 1997 to 927 FTEs in FY 1998, with 679 paid staff
working full-time on the program. The number of volunteers who
are trained and certified to investigate complaints increased
from 6,795 in FY 1997 to 7,359 in FY 1998. Most state ombudsman
programs are located in state agencies on aging, but programs
in 15 states are located in other types of organizational
settings, a slight increase since FY 1997.
Report on the American Indian, Alaskan Native and Native Hawaiian
Program
The Office for American Indian, Alaskan Native and Native
Hawaiian programs serves as the focal point within the AoA for
the operation and assessment of Native American programs
authorized under Title VI and oversight of the Native American
Elders Resource Centers authorized under Title IV. The Office
Director continues to serve as the effective and visible
advocate on behalf of older Native Americans, coordinates
activities with other Federal departments and agencies,
collects and disseminates information related to the problems
of older Native Americans, and promotes coordination between
the administration of Title III and Title VI.
Title VI--Grants for Native Americans
Under Title VI of the OAA, the AoA annually awards grants
to provide supportive and nutritional services for older
American Indians, Alaska Natives and Native Hawaiians.
Title VI, Grants to Indian Tribes, was added to the OAA in
the 1978 amendments and was expanded by the 1987 Amendments to
include Native Hawaiians.
In Fiscal Year 2000 grants totaling $18,457,000 were
awarded to 225 American Indian and Alaska Native Tribal
Organizations, and two organizations serving Native Hawaiians,
to provide congregate and home-delivered meals and a variety of
supportive services. As required by the OAA, 90 percent of the
funds went to the Tribal organizations and 10 percent went to
the Native Hawaiian organizations.
Nutrition services are a major component of Tribal Title VI
programs. Native elders receive nearly three million congregate
and home-delivered meals annually. Most program sites provide
hot congregate meals four to five times a week. Home-delivered
meals are delivered five times a week for elders who generally
are in poorer health, are more functionally impaired, get out
of their homes less often, and need in-home supportive
services. Most programs provide modified diets for diabetics,
or others who might be on low-fat, low-cholesterol, and low-
sodium diets. Several programs provide special nutrition
services such as meals for homeless older persons an evening
meal option for home-delivered meal participants, and weekend
home-delivered meals.
In addition to providing meals, nutrition education,
screening, and counseling, Title VI programs are important
resources for social interaction and supportive services. For
example, congregate meal programs provide Native elders with
important opportunities to meet with friends, participate in
recreation and other activities, and take trips to other elder
programs or state and national meetings. Other vital supportive
services can include outreach, family support, legal
assistance, and transportation to meal sites, doctor's
appointments, and grocery shopping. Most programs offer health-
related services, such as podiatry screening and blood pressure
monitoring.
Tribal Listening Session
President Clinton signed an Executive Memorandum on April
29, 1994 affirming that the United States government maintains
the unique relationship with Indian Tribes founded on the
principle of government-to-government relations. Consistent
with this relationship, the AoA hosted a Tribal Listening
Session on August 8, 2000 in Washington, DC with Tribal leaders
throughout the country. The Session focused on issues affecting
the lives of Indian elders. There were over 100 participants
representing Tribes nationally. The Listening Session allowed
for an open dialogue addressing four priority areas: 1) policy
directions; 2) capacity building; 3) health care; and 4) long-
term care. Recommendations were made by the participants in
these four areas and are currently being reviewed and
addressed.
National Resource Centers
Since 1994, AoA has awarded grants to two universities to
establish National Resource Centers for Older American Indians,
Alaska Natives, and Native Hawaiians. The University of
Colorado at Denver and the University of North Dakota at Grand
Forks provide culturally competent health care resources,
community-based long term care information, and related
services. They serve as the focal points for developing and
sharing technical information and expertise for American Indian
organizations, Native American communities, educational
institutions, and professionals and others working with Native
elders.
Interagency Task Force on Older Indians
The 1987 Amendments in Section 134(d) directed the
Commissioner on Aging to establish a permanent Interagency Task
Force on Older Indians, with representative of federal
departments and agencies who work to improve services to older
American Indians. This Task Force was established in Fiscal
Year 1990. Task Force members focus on three areas of concern:
health, transportation, and data. The Task Force recommends
ways to improve interagency collaboration, enhance services,
and identify problems or barriers that prevent or diminish
collaboration.
Discretionary Grants Program
The Administration on Aging supports a number of
demonstration programs, national resource centers, and related
discretionary grant projects under the authority of Title IV of
the Older Americans Act, the Health Insurance Portability and
Accountability Act, and the Public Health Services Act. The
principal AoA discretionary grants program efforts are
summarized below:
Health Care Fraud and Abuse Control Program Activities
The General Accounting Office estimates that billions of
Medicare and Medicaid dollars are lost each year to waste,
fraud and abuse. The AoA has played an active role in the
ongoing effort to address this serious national problem through
the enactment of P.L. 104-209, the Omnibus Consolidated
Appropriations Act of 1997. Language contained in Title IV of
the Older Americans Act directs the AoA to establish community-
based projects that utilize the skills and expertise of retired
professionals in identifying and reporting waste, fraud and
abuse. The projects are designed to recruit and train retired
professionals, such as doctors, nurses, teachers, lawyers,
accountants, and others to work in their communities and in
local senior centers to help identify deceptive health care
practices, such as over billing, overcharging, or providing
unnecessary or inappropriate services. These senior volunteers
undergo several days of training reviewing health care benefit
statements and outlining steps individuals can take to protect
themselves.
AoA also receives funding under the Health Insurance
Portability and Accountability Act of 1996 to work in
partnership with the Health Care Financing Administration, the
Office of Inspector General, the Department of Justice, and
others in a coordinated effort to combat and prevent waste,
fraud, and abuse in Medicare and Medicaid. The AoA's efforts
under this initiative have been to: 1) train professionals who
provide services to older Americans about how to recognize and
report potential instances of waste, fraud, and abuse; 2)
support the work of four technical assistance resource centers
which provide outreach activities to rural, isolated, or
limited English-speaking individuals; 3) develop consumer
education materials in English, Spanish, and Chinese; and 4)
convene annual national and regional conferences which bring
together government officials, health care professionals, aging
service providers, and older Americans to share common
strategies and practices.
Working in partnership with partners at the federal, state,
and local levels, the Medicare error rate has been reduced by
more than 40 percent over the past three years, and billions of
dollars of improper payments have been returned to the Medicare
and Medicaid programs.
Over the past three years, the AoA's projects supported by
Title IV of the Older Americans Act and the Health Insurance
Portability and Accountability Act have a commendable track
record:
They have trained more than 40,000
volunteers and aging service professionals to serve as
community resources and educators.
These volunteers and professionals in turn
have conducted more than 25,000 community education
events and one-on-one counseling sessions, directly
educating more than one million beneficiaries.
The projects also held more than 2,500 media
events, reaching more than an estimated 45 million
people.
During this time period, more than 2,300
complaints have been referred to health care providers,
Medicare contractors, the Office of Inspector General,
or other appropriate entities for follow-up
investigation and correction.
While it has not been possible to document
the results of all the cases referred by the AoA's
grantees, nearly $58 million in savings have been
documented as being directly related to the efforts of
the projects.
The heightened awareness of beneficiaries
checking their Medicare Summary Notices and Explanation
of Medicare Benefit statements has contributed to a 42
percent reduction in the Medicare error rate since the
projects have been in operation.
Pension Information and Counseling Program
Now located in 14 states (Arizona; California; Connecticut;
Illinois; Maine; Massachusetts; Michigan; Minnesota, Missouri;
New Hampshire; New York; Rhode Island; Vermont; and Virginia),
the pension counseling demonstration projects supported by AoA
since 1993 have assisted over 10,000 older Americans with
pension problems. The projects have been instrumental in
recouping over $30 million in pension claims. Each of the
pension counseling projects brings its own unique model to the
program. Some projects operate with full-time lawyers, others
rely on highly trained volunteers to provide assistance. The
projects provide a range of services, from answering pension
questions to providing legal assistance to obtain promised
pension benefits.
Each of the demonstration projects offers several basic
services:
Counseling and assistance to older
individuals and their families who need help in
determining their rights and in following the process
for filing claims or complaints related to pension and
other retirement benefits;
Information on sources of pension and other
retirement benefits;
Referrals to attorneys, actuaries, legal
services and other advocacy programs;
Outreach programs to provide information,
counseling, assistance and referral regarding pension
and other retirement benefits with special emphasis on
outreach to women; minority; rural, and low-income
retirees.
The Pension Rights Center in Washington, DC, with financial
assistance from the Administration on Aging, provides technical
assistance to individual pension projects, state and area
agencies on aging, and legal services providers on pension
issues, and encourages these groups to coordinate their
activities with other federal agencies. The Center also
provides training for staff and volunteers working in pension
demonstration projects.
Elder Rights and Legal Assistance Program
AoA support for model projects and resource centers under
its Elder Rights and Legal Assistance Program is summarized
below:
(1) Statewide Senior Legal Hotlines
Model legal hotlines, utilizing paid, specially-trained,
and experienced lawyers, are designed to provide unlimited free
legal advise to all state residents age 60 and older,
regardless of their level of income or resources. The hotlines
also provide legal briefs and related assistance such as
document reviews and calls/letters to third parties, but only
when there is a likelihood that this would resolve the problem.
Services are provided statewide by means of toll-free telephone
lines. Currently, AoA is supporting senior legal hotlines in
northern California, Georgia, Hawaii, Indiana, Iowa, Kentucky,
Maine, Maryland, Michigan, New Hampshire, Tennessee,
Washington, and West Virginia.
(2) National Legal Assistance Support Projects
The Older Americans Act mandates the support, under Title
IV, of a national system of legal assistance support activities
to State and Area Agencies on Aging which will assist them in
developing an elder rights system and in providing, developing
and supporting legal assistance for older people. In the 1992
amendments to the Older Americans Act, legal assistance was
made an integral part of the new Title VII, Vulnerable Elder
Rights Protection program. As a result, AoA expanded the role
of the national system to encompass elder rights systems
development. Five (5) national level providers of legal support
and assistance are now being funded by AoA through 2001.
(3) National Resource Centers to Protect Elder Rights
Two centers active nationwide (the National Center on Elder
Abuse and the National Long Term Care Ombudsman Resource
Center) have been funded by AoA since 1993 to provide findings,
products, information, training, and technical assistance that
would help to safeguard the rights of older persons living in
residential and institutional settings.
Reach 2010 for the Elderly
In FY 2000, the AoA joined with the Centers for Disease
Control and Prevention to strengthen the scope of the
departmental initiative to eliminate health disparities among
racial and ethnic minority populations by mounting REACH 2010
for the Elderly. This major collaborative effort has the goal
of improving the health status of older racial and/or ethnic
minority persons. Four projects were funded to support
community coalitions in their groundbreaking initiatives to
reduce health care disparities in the areas of heart disease,
diabetes, and immunization. The Reach 2010 grantees are as
follows:
Boston Public Health Commission
The Latino Education Project
Special Services for Groups
National Indian Council on Aging
Other Significant Discretionary Program Efforts
Other noteworthy AoA-supported discretionary programs and
projects include the Alzheimer's Disease Demonstration Grants
to States Program, the Family Friends/Volunteer Senior Aides
program, the National Eldercare Locator, minority aging model
projects, and home and community based long term care
demonstration projects.
2. Program Direction
----------------------------------------------------------------------------------------------------------------
FY 1999 FY 2000 FY 2001
----------------------------------------------------------------------------------------------------------------
Supportive Services & Centers.......................... $309,957,000 $310,020,000 $325,082,000
Congregate Meals....................................... 374,261,000 374,336,000 378,412,000
Home-Delivered Meals................................... 112,000,000 146,970,000 152,000,000
Preventive Health Services............................. 16,123,000 16,120,000 21,123,000
State and Local Innovations/Projects of National 18,000,000 31,156,000 37,678,000
Significance..........................................
Grants to Native Americans............................. 18,457,000 18,457,000 23,457,000
Vulnerable Older Americans............................. 12,181,000 13,179,000 14,181,000
Alzheimer's Disease.................................... 5,970,000 5,968,000 8,970,000
Program Administration................................. 14,781,000 16,458,000 17,232,000
TOTAL, Budget Authority................................ $881,730,000 $932,664,000 $1,103,135,000
----------------------------------------------------------------------------------------------------------------
FY 1999
In FY 1999, AoA programs were funded at a total of $881.7
million, an increase of almost $11 million over FY 1998. The
majority of this money was allotted by statutory formula to
states and territories. Funding for the major supportive
services and nutrition programs remained unchanged; increases
were provided for several smaller AoA programs. Vulnerable
Older Americans did receive an additional $3 million (+33%) to
increase Ombudsman activities. AoA's sole discretionary grant
program, State and Local Innovations and Projects of National
Significance received $18 million, the largest increase, +$8
million (+80%). In FY 1999 the number of projects funded under
this discretionary authority increased from approximately 61 to
105 and included the Eldercare Locator, Senior legal hotlines,
pension counseling, and evaluation activities.
FY 2000
In FY 2000, AoA programs were funded at a total of $932.7
million, an increase of $51 million. Home-Delivered meals, one
of AoA's two formula grant nutrition programs, received an
additional $35 million, a +31 percent increase. Funding for
AoA's other formula grant programs again remained static. The
increase for Home-Delivered meals allowed grantees to provide
nearly 166,000,000 meals to frail, home-bound elders.
Vulnerable Older Americans also received a $1 million increase,
again for the Ombudsman program. And once again, State and
Local Innovations and Projects of National Significance
received a large increase (73%) bringing the program level to
over $31 million and funding approximately 70 new projects, 120
projects total. Program Administration also received a nearly
$2 million increase to fund staff increases and increased costs
of facilities rental, automated systems support, travel,
supplies and equipment.
THE FUTURE
In FY 2001, the start of which covers the final three
months in calendar year 2000, funding for Aging programs has
increased significantly, to a total of $1.1 billion or $169
million over the FY 2000 level. This includes $125 million for
a new National Family Caregiver Support Program to provide
support to the 7 million informal caregivers of older
Americans. In addition, the FY 2001 budget includes increases
for each of its core services and programs, including home-
delivered and congregate meals; preventive health; grants to
Native Americans, programs which protect the rights of the
vulnerable, as well as an increase for the Alzheimers Disease
Demonstration Project Grants to States.
Accomplishments of the Administration on Aging: 1999-2000
Administration/Departmental Initiatives
Since 1995, the Administration on Aging has been a partner
in the Administration's Operation Restore Trust initiative,
along with HCFA, the Office of the Inspector General, and the
Department of Justice to combat waste, fraud and abuse in
Medicare and Medicaid. AoA has trained state and local
ombudsmen and volunteers, aging network personnel, including
staff and volunteers of State and Area Agencies on Aging,
health insurance counselors and other service providers to
identify and report suspected fraud and abuse. In FY 2000, $10
million in grants was awarded to 48 ``Senior Medicare Patrol
Projects'' operating in 43 states plus the District of Columbia
and Puerto Rico. These projects have trained approximately
30,000 senior volunteers and aging network staff and educated
650,000 beneficiaries to identify and report suspected cases of
fraud and abuse.
Reauthorization of the Older Americans Act (OAA) with
inclusion of the National Family Caregiver Support Program,
part of the Administration's Long Term Care Initiative unveiled
in 1999, which will help hundreds of thousands of family
members care for their older family members by providing
respite care and supplemental services, information,
assistance, training, support and counseling. FY 2001 funding
for the National Family Caregiver Support Program is $125
million.
Public Information/Customer Service
Launching of AoA's web site in 1995, a major source of
timely and useful information to older people, the national
aging network, policymakers. AoA's web site has been expanded
to include limited access web sites for the Federal
Coordinating Committee of the International Year of Older
Persons (1999); a limited Spanish web site containing resource
and referral information to those interested in Hispanic aging
and health issues, and an independent web site dedicated to
providing and sharing information about the Administration on
Aging's role in the Administration's effort to fight fraud,
waste and abuse in Medicare and Medicaid. In FY 2000, a
minority/aging issues limited access web site and an on-line
caregivers guide called ``Because We Care'' was added.
Institution in 1999 of a limited access list serve
specifically devoted to national aging network of state and
area agencies on aging responsible for the collection and
reporting program performance data to the Administration on
Aging. Through NAPISNEWS, customized information and technical
assistance can be quickly disseminated and provided to
appropriate staff throughout the country.
Creation of a Congressional mandated National Aging
Information Center to provide convenient access to a wide range
of resources for those interested in aging issues and
information. The Center serves the aging network, educators,
researchers, practitioners and the general public.
Establishment of AoA's national disaster assistance program
to assist older persons and representatives of the aging
network in recovery efforts from Presidentially declared
disasters. Since 1993, the Administration on Aging in
collaboration with its state and area agencies on aging, FEMA,
and the Red Cross has provided approximately $17.5 million in
disaster relief to thousands of older persons in immediate need
of assistance.
Medicare+Choice
Since 1998, AoA has worked in partnership with the Health
Care Financing Administration (HCFA) to support Medicare+Choice
(M+C) implementation. Through the Information and Referral for
Medicare Beneficiaries Projects, AoA was able to provide funds
to State Units on Aging (SUAs) to strengthen the capability of
information and referral providers at the State, Area Agency
and local levels to respond to inquiries regarding M+C. In
addition, AoA worked in collaboration with it's National
Information and Referral Support Center and HCFA to develop the
Medicare+Choice Training Manual for Older Americans Act
Information Referral & Assistance Programs. The manual was
provided to State Units on Aging and Area Agencies on Aging to
assist them in developing Medicare+Choice training and outreach
activities. Over 15,000 information and referral specialists
and other Aging Network staff have received training as a
result of this collaborative effort.
National Symposia on Longevity
The Administration on Aging convened two symposia during
1999 and 2000 which focused on the implications of a long
living society. The symposia were designed to increase public
awareness of longevity, provide a forum for dialogue about the
implications for research, policy, programs and services, and
foster the development of partnerships and collaborations
between a variety of organizations. The first symposium focused
on the most potent and promising research findings related to
caregiving, economic security, health, population diversity,
consumer protection, information and technology and media
relations. The second symposium bridged the gap between
research and practice by providing the participants evidenced-
based, outcomes-oriented methods and tools that could be used
to plan, develop and modernize services and programs for
America's diverse and growing older population.
Programs and Services for Older Americans
The Older Americans Act continues to provide essential home
and community services for older persons, and their family
members such as nutrition, transportation, and legal
assistance, through a national aging network of 57 State
offices on aging, 655 area agencies on aging, 225 Tribal
Organizations, service providers and volunteers.
Nutrition
Release of a Congressionally mandated evaluation of the
Elderly Nutrition Program under the Older Americans Act (OAA)
to determine the effectiveness of the Elderly Nutrition Program
in meeting the nutritional needs of older persons as well as
meeting unmet needs. Key findings include determination that
the highly successful OAA Elderly Nutrition program provides an
average of one million meals per day to older Americans;
between 80 and 90 percent of participants have incomes below
200 percent of the DHHS poverty level, and more twice as many
of the participants live alone.
Establishment of the National Policy and Resource Center on
Nutrition and Aging which focuses on providing information
dissemination, training and technical assistance and policy
analysis on issues related to nutrition and older persons.
The Morning Meals on Wheels Program Initiative was launched
in 20 communities across the United States. This is a
partnership with General Mills Food service and the
Administration on Aging to provide at-risk older Americans with
additional food and nutrition security. Morning Meals on Wheels
provides home elders with a morning meal delivered to their
door in addition to their regularly scheduled noon meal.
Alzheimer's Disease Demonstration Grants program was
transferred from HRSA to AoA. Sixteen new ADDGS grants were
funded in 2000, to expand support efforts for persons with
Alzheimer's Disease and their caregivers.The program emphasizes
outreach to under served populations and regions, program
development, service delivery systems and information
dissemination.
AoA convened its first Tribal Listening Session to Native
American elder issues. The session gave American Indians,
Alaska Natives, and Native Hawaiian representatives the
opportunity to discuss policy directions and capacity building
in areas such as long term care, health promotion, and support
services needed in the future. Greater numbers of Native
Americans are living well into their 80's and 90's. AoA funds
225 tribal organizations representing more than 300 American
Indian and Alaska Native tribes and two organizations serving
Native Hawaiians, through Title VI of the Older Americans Act.
Consumer Protection
Release of the National Elder Abuse Incidence Study which
found that more than one half million older Americans, mostly
older women, suffered some form of abuse and neglect in 1996,
most at the hands of their family members.
Entered into Interagency Agreement with the Department of
Justice to address the public safety and security needs of
older Americans. Activities have included promotion of local
and state TRIAD programs, which are efforts to increase
cooperation between law enforcement and aging and social
services providers to reduce criminal victimization.
Funding a new National Center on Elder Abuse to be operated
by the National Association of State Units on Aging in
partnership with the other advocacy organizations to facilitate
training and technical assistance between state and local
service providers, including older Americans, working to
prevent elder abuse.
Establishment of Pension Counseling and Counseling program
including 10 AoA-funded pension demonstration projects serving
14 states and one technical assistance Project for a total of
$3.3 million dollars. These projects have assisted 30,000
retirees, older employees and their spouses or widows/widowers
to determine whether or not they are receiving the amount of
retirement benefits to which they are entitled. The project has
recouped at least $21 million in pension benefits on behalf of
their clients returning $7 for every $1 spent to older
Americans. AoA also released results of a two-year
Congressional study of the Pension Counseling Program, which
found that basic pension counseling for older workers and
retirees is needed, can be easily provided at a moderate cost
by training volunteers, and can yield substantial individual
and collective savings.
Design and Implementation of the National Ombudsman
Reporting System (NORS) to obtain needed detailed ombudsman
complaint and program information in an effort to design policy
and serve as a baseline against which to measure program
outcomes in future years. Funding of the National Long Term
Care Ombudsman Resource Center, which provides training and
technical assistance to state and local ombudsmen across the
country.
Partnership with the Federal Deposit Insurance Corporation
in the Financial Literacy, Y2K and Banking Campaign, a public
awareness campaign to promote financial literacy in particular
between women and low income and minority populations.
Promoting Health and Quality of Care
AoA has awarded four demonstration grants to expand the
Centers for Disease Control's Reach 2010 (Racial and Ethnic
Approaches to Community Health 2010) initiative. This grants
will permit four communities to develop science based,
community demonstration projects to address health disparities
in older, racial and ethnic minority populations.
AoA and HCFA joined forces to improve the quality of care
in nursing homes. Nearly one half million dollars has been
dedicated to support 4 demonstration projects to educate and
empower communities and families to improve nutrition and
hydration, and prevent abuse of nursing home residents.
Management
To develop the national core set of performance outcome
measures for aging services required by the Government Results
and Performance Act, AoA is building on performance outcome
measures currently in use by state and area agencies. Seventeen
State and Area Agency partners are working to address the
elements of data collection; analysis and recommendations;
pilot testing, and dissemination, utilization and mentoring
activities.
The Administration on Aging was one of the first in HHS to
undertake a workforce planning process. In early 1999, it
completed a workforce plan to identify requisite knowledge,
skills, and abilities for management and staff to be able to
formulate, implement and assess programs and policies related
to older persons and their families. The workforce plan serves
as a guide for the recruitment and hiring of new managers and
staff.
The Administration on Aging embarked upon the reorientation
of its Central and Regional Office program and policy foci in
order to respond more effectively to the growing numbers and
the increasing diversity of older Americans and their families,
baby boomers anticipating their older years, and of populations
at greater risk of chronic illness, disability and economic
security.
International Activities
AoA chaired and led national federal activities for the
International Year of Older Persons, designated by the UN for
1999. As head of the Federal Committee for the International
Year for Older Persons, AoA convened the first ever federal
symposium ``Coming of Age: Federal Agencies and the Longevity
Revolution.'' As part of the IYOP activities, the Assistant
Secretary for Aging addressed the 54th Session of the United
Nations General Assembly on the aging challenges of a longer
living U.S. society.
Joined as a partner with Sister Cities International, Inc.
which joins aging professionals and volunteers in the US with
their counterparts in other countries to provide technical
assistance in meeting the needs of any population.
The Administration on Aging is a principal partner in the
US-Mexico Bilateral Commission Health Working Group convened as
part of the 1996 Annual Meeting of the US-Mexico Bilateral
Commission. AoA assists in the identification of public health
issues that effect both countries including aging, migrant
health, prevention of tobacco abuse, women's health,
immunization, and substance abuse.
AoA was a member of the 1999 World Health Day Advisory
Committee. ``Healthy Aging'' was designated by the World Health
Organization as the topic of World Health Day 1999. In the US,
the theme ``Healthy Aging, Healthy Living - Start NOW! was
selected by the American Association for World Health and the
advisory committee as fitting since 1999 was IYOP.
Network Security/Y2K
AoA was the first in the Department of Health and Human
Services to achieve Y2K compliancy, and worked for two years
with its national aging network of state and area agencies on
aging to ensure they were ready for the year 2000.
Security of AoA's computer network has been improved in
response to the President's Decision Directive 63 concerning
anticipated cyberterrorism.
OFFICE OF THE ASSISTANT SECRETARY FOR PLANNING AND EVALUATION
The Office of the Assistant Secretary for Planning and
Evaluation (ASPE) serves as the principal advisor to the
Secretary on policy and management decisions for all groups
served by the Department, including the elderly. ASPE oversees
the Department's legislative development, planning, policy
analysis, and research and evaluation activities and provides
information used by senior staff to develop new policies and
modify existing programs.
ASPE is involved in a broad range of activities related to
aging policies and programs. It manages grants and contracts
which focus on the elderly and coordinates other activities
which integrate aging concerns with those of other population
groups. For example, the elderly are included in studies of
health care delivery, poverty, State-Federal relations and
public and private social service programs.
ASPE also maintains a national clearinghouse which includes
aging research and evaluation materials. The ASPE Policy
Information Center (PIC) provides a centralized source of
information about evaluative research on the Department's
programs and policies by tracking , compiling, and retrieving
data about ongoing and completed HHS evaluations. In addition,
the PIC data base includes reports on ASPE policy research
studies, the Inspector General's program inspections and
investigations done by the General Accounting Office and the
Congressional Budget Office. Copies of final reports of the
studies described in this report are available from PIC.
During 2000, ASPE undertook or participated in the
following analytic and research activities which had a major
focus on the elderly.
1. Policy Development--Aging
Federal Interagency Forum on Aging-Related Statistics
ASPE is a member of the Federal Interagency Forum on Aging-
Related Statistics. The Forum was established to encourage the
development, collection, analysis, and dissemination of data on
the older population. The Forum seeks to extend the use of
limited resources among the agencies through joint problem-
solving, identification of data gaps, and improvement of the
statistical information bases on the older population. The
primary goals of the Federal Forum were to provide federal
agencies a venue for discussing aging-related data issues and
concerns that cut across agency boundaries, facilitate the
improvement of existing aging data bases and the development of
new sources of information, improve the dissemination of
information on aging-related research and data, and encourage
cross-national research and data collection on population
aging. The Federal Forum was instrumental in gathering support
for several important surveys of the aging U.S. population
(e.g., the Health and Retirement Survey, the survey of Assets
and Health Dynamics Among the Oldest-Old, and the Second
Longitudinal Study of Aging) and produced several stand-alone
reports including Trends in the Health of Older Americans and
65+ in the United States.
2. Research and Demonstration Projects
Panel Study of Income Dynamics
University of Michigan, Institute for Social Research
Principal Investigators: James N. Morgan, Greg J. Duncan,
Martha S. Hill
Through an interagency consortium coordinated by the
National Science Foundation, ASPE assists in the funding of the
Panel Study of Income Dynamics (PSID). This is an ongoing
nationally representative longitudinal survey that began in
1968 under the auspices of the Office of Economic Opportunity
(OEO). The PSID has gathered information on family composition,
employment, sources of income, housing, mobility, health and
functioning, and other subjects. The current sample size is
over 7,000 persons, and an increasing number of them are
elderly. The data files have been disseminated widely and are
used by hundreds of researchers in this and other countries to
get an accurate picture of changes in the well-being of
different demographic groups, including the elderly.
Funding: ASPE and HHS precursors: FY67 through FY79--
$10,559,498; FY80--$698,952; FY81--$600,000; FY82--$200,00;
FY83--$251,000; FY84--$550,000; FY85--$300,000; FY86--$225,000;
FY87--$250,000; FY88--$250,000; FY89--$250,000; FY90--$300,000;
FY93--$300,000; FY94--$800,000; FY95--150,000; FY96--205,000;
FY97--100,000; FY98: $200,000
End Date: Ongoing
1999 NLTCS/ICS: File Preparation and Preliminary Data Analysis
MEDSTAT Group
The purpose of this project is to prepare the 1999 NLTCS/
ICS data file for analysis and to perform some preliminary
descriptive analyses. This is a necessary prerequisite for more
detailed analyses, which will be used to update the ASPE
booklet ``Informal Caregiving: Compassion in Action''
(published in 1998, based on 1995 NLTCS data).
Funding: $49,452 (FY00)
End Date: September 30, 2001
A Comparative Study of the Outcomes and Costs Associated with Medicare
Post-Acute Services in Skilled Nursing Facilities,
Rehabilitation Hospitals/Units, and Home Health Settings
University of Colorado
Using the outcome measurement instrument developed for
patients suffering from a stroke (i.e., developed under the
project Medicare Post-Acute Care: Quality Measurement), two
projects have been combined to study the outcome and costs of
Medicare post acute care services for Medicare beneficiaries
who have suffered a stroke and are discharged from acute care
hospitals to skilled nursing facilities (SNFs), rehabilitation
hospitals/units (RFs), home health agencies (HHAs), or use
multiple post-acute care settings. These studies will examine
in a post-prospective payment system environment the: (1)
demographic and health related characteristics of and assess
the extent of overlap in stroke patients treated in each of the
post-acute care settings; (2) patterns of service use and costs
associated with the treatment of similar patients in each
setting and across episodes of care; (3) outcomes across an
episode of care for similar Medicare beneficiaries treated by
each post acute provider type and those treated by multiple
providers; (4) the relationship between outcomes for similar
patients and differences in the mix and intensity of services
provided, and level of reimbursement across post acute care
providers and episodes of care; and (5) core measures that are
most useful to incorporate into on-going reporting requirements
to monitor outcomes in each post-acute care setting and across
episodes of care.
Funding: Total Award $1,593,536 (FY99 $898,956; FY00
$694,580)
End Date: August 28, 2003
Analyses of Changes in Elderly Disability Rates: Implications for
Health Care Utilization and Costs
The Urban Institute
The purpose of this project is to conduct analyses using
the 1984 to 1999 National Long-Term Care Survey (NLTCS) and the
Medicare Current Beneficiary Survey (MCBS) to understand the
nature of recent declines in elderly disability rates and their
implications for health care utilization and costs.
Specifically, researchers at The Urban Institute are (1)
decomposing changes in elderly disability rates using the 1984
to 1999 NLTCS and exploring possible reasons for the decline,
and (2) linking changes in elderly disability rates to the use
of specific medical procedures (e.g., cataract surgery,
coronary and joint replacement surgeries) and/or assistive
technology. The MCBS is the primary data set for the latter
analyses.
Understanding the structure of the decline will give us our
first clues as to the reasons for the overall decline, the
likelihood that disability rates will continue to fall in the
future, and its potential impact on health care spending.
Current hypotheses for the decline include improvements in
nutrition (including advances in food preparation and storage
over the century), healthier life-styles (higher levels of
physical activity, lower levels of drinking and smoking),
better treatment of chronic diseases through medical procedures
and pharmaceuticals, and use of assistive devices and
technology. It is likely that future improvements in disability
and changes in health care utilization and spending will be
heavily dependent on which of these hypotheses is correct. For
example, if declines in disability rates are due primarily to
improvements in IADLs or equipment use and reflect
environmental changes rather than improvements in the intrinsic
health of the elderly population, then the declines observed
over the last decade may not continue into the next century and
may have limited impact on acute health care spending. This
project is a first step in understanding the policy
implications of the changes that we are observing in elderly
disability rates.
Funding: $254,409 (FY99 $179,409; FY00 $75,000)
End Date: December 31, 2001
Analyses of Residential Transition of Older Americans.
Urban Institute
There are four main questions to be addressed in this
project: (1) How do characteristics (both individual and
environmental) of elderly persons residing in institutional
settings differ from those residing in community-based
settings? (2) How do these characteristics vary over time? (3)
Are there differences in these characteristics between
subgroups of institutionalized and non-institutionalized
elderly? (4) What is the relationship between selected
individual and environmental factors and the transition of the
elderly between community and institutional residential
settings? Data from six years of the Medicare Current
Beneficiary Survey will be used to answer these questions.
Understanding residential transitions will help staff in the
Department improve surveys that monitor acute health and long-
term care use in different settings (e.g., the Medical
Expenditure Panel Survey) and address outstanding long-term
care policy issues (e.g., allocation of resources between
community and institutional settings).
Funding: Total Award $153,494 (FY00 $153,494)
End Date: March 31, 2002
Assessment of Home Care Benefits Used by Holders of Private Long-Term
Care Insurance
Life Plans, Inc.
Most experts agree that long-term care insurance products
must include both nursing home and home care benefits if they
are to be commercially acceptable. Yet private insurers as well
as public payers are concerned about their ability to control
home care claims, particularly given the potential substitution
of formal home care services for care provided by families. The
purpose of this study was to collect detailed information on
the experience of long-term care policy holders who have filed
insurance claims to receive home care benefits and how their
formal and informal service use compares to a comparable
population of elderly persons without private insurance.
Primary data collection involved face-to-face interviews with
approximately 1,000 persons (500 disabled insurance claimants
and 500 next-of-kin of those claimants) to collect information
on functional and medical characteristics of claimants as well
as formal and informal services use. The sample of claimants
was drawn from the files of insurance companies that account
for the majority of private long-term care policies now in
force.
Funding: $50,000
End Date: March 1, 2000
Case Studies of Nursing Home Transition Programs
Medstat Group
The purpose of this project is to conduct case studies of
Nursing Home Transition Programs in up to eight states (with
possible additions depending on future grant awards). The
programs being evaluated were developed and implemented with
funding from an ongoing grant initiative sponsored by the
Health Care Financing Administration (HCFA) and the Office of
the Assistant Secretary for Planning and Evaluation (ASPE). A
case study approach is proposed for two reasons: (1) the vast
differences in state Medicaid programs, state long-term care
infrastructures, and proposed nursing home transition programs;
and, (2) the small number of nursing home residents expected to
participate in the transition programs.
Each case study will attempt to determine the most
significant barriers faced by nursing home residents in
returning to the community, and, to glean the relative success
or failure of the strategies used by grantees to overcome these
barriers. As HCFA and ASPE intend to continue making additional
grants in this area, an evaluation of grantee activity will
assist federal policy makers in further grant making, and state
policy makers in developing transition programs.
Funding: Total Award $300,006 (FY00 $300,006)
End Date: February 1, 2002
Characteristics of Nursing Home Residents
Hebrew Rehabilitation Center for Aging
Caring for persons with disabilities in the least
restrictive setting is a major long-term care policy objective.
It is important to identify nursing home residents who could be
discharged to the community if appropriate home and community-
based services were available. This project will analyze data
from a new source--the Minimum Data Set (MDS)--in nine states.
The MDS consists of assessments which have been conducted on
all nursing home residents in selected States as part of a HCFA
demonstration (and starting in the summer of 1998, the data
will be collected in electronic form in all 50 States). We will
learn much more about the medical conditions, functional needs,
and specific services used by nursing home residents than was
possible with previous data sets. We will also be able to study
important subpopulations, especially the nonelderly. The policy
implications of the findings will be assessed.
Funding: Total Award $150,000 (FY98 $150,000)
End Date: September 30, 2001
Evaluation of Practice in Care (EPIC)
University of Colorado
From 1989 to 1992, there was a 210 percent increase in
Medicare expenditures for home health services. This increase
in utilization has generated widespread policy interest in
appropriate measures to control expenditures without
compromising quality. Medicare home health has been the subject
of considerable research, but the actual practice of home
health care has not been extensively examined. This study will
analyze ``episodes'' of care under the Medicare home health
benefit, assess the actual practice of care, the extent to
which there is variation in practice between acute and long-
term patients, and the factors that account for that variation.
This study will also examine decision-making processes between
patients, providers and physicians. What takes place during a
visit and between visits as ``actual practice'' has never been
measured. Furthermore, the function of decision-making by
various parties has not been observed in ``actual practice.''
This effort to understand issues surrounding regional and
practice variations of home health care delivery will aid the
Department and the industry in combating fraud and abuse, as
well as contribute valuable data to a future prospective
payment system.
Funding: Total Award $1,400,000 (FY97 $200,000)
End Date: March 1, 2001
Informal Caregivers Supplement to the 1999 National Long-Term Care
Survey.
Duke University
The Office of the Assistant Secretary for Planning and
Evaluation (ASPE) has been involved in the past in designing a
modest respite benefit for Medicare beneficiaries with
Alzheimer's disease for inclusion in the President's budget. In
1998, there is renewed interest in having proposals for respite
services and other caregiver supports, on a broader scale,
incorporated into the President's long-term care budget
initiative. We are currently working with White House, OMB, and
Treasury staff to explore the use of tax incentives to help
informal caregivers be able to afford paid home care services
as a supplement to their own informal efforts. In order to
respond to these kinds of policy analysis requests, it is
important for ASPE to look ahead and anticipate future data
needs. In this case, the need is to have data collection
mechanisms in place to track, over time, changes in the
characteristics of informal caregivers of the disabled elderly,
as we have to follow changes in the population of disabled
elders themselves. ASPE supported the first and second Informal
Caregiver's Supplement to the National Long-Term Care Survey in
1982 and 1989 respectively. A third round of data collection on
informal caregivers is now needed in order to remain up-to-
date.
Family members typically initiate the process of nursing
home placement for disabled elders when they feel that the
disabled elder needs more help than can be provided in a home
setting. Often families come to such a decision when one or
more family caregivers have been providing upwards of 60 hours
per week of unpaid assistance. This project will enable in-
depth analysis of the conflicts informal caregivers experience
between employment and eldercare as well as provide information
about the health status of caregivers and measures of caregiver
stress and burden. These data can then be used in crafting
policy initiatives to support caregivers and prevent
``caregiver burnout'' which could result in premature
institutionalization. It will help determine whether and to
what extent caregivers' age, marital status, relationship to
the care recipient, household income, employment, health
status, and various measures of caregiver stress and burden are
associated with greater or lesser use of supplemental formal
care. We will also be able to measure the extent to which
caregivers as well as the disabled elders themselves experience
out-of-pocket spending for supplemental home care.
Funding: Total Award $300,000 (FY98 $300,000)
End Date: March 1, 2000
Long-Term Care Microsimulation Model
Lewin Group
This project will update and expand the capability of the
Brookings/ICF Long-Term Care Financing Model, which currently
takes a national sample of persons, ages them over time, and
estimates their long-term care use and financing when they
become elderly. It will incorporate results from recent surveys
of nursing homes and home care utilization; e.g., the 1989 and
1994 National Long-Term Care Surveys. The model will also be
expanded to include acute care use and expenditures, and the
period of simulation will be extended to 2030. The economic
assumptions will be updated.
The model will continue to be used to project future trends
and to perform policy simulations, including expanded coverage
for nursing home and home care, changes in Medicaid eligibility
and services, and expanded enrollment in private long-term care
insurance plans. It will also be used to estimate the impact of
changing trends in disability and the combined burden of acute
and long term care services on the elderly.
Funding: $1,304,820 (FY97 $232,266; FY98 $211,709)
End Date: December 31, 2000
Managed Delivery Systems for Medicare Beneficiaries with Disabilities
and Chronic Illnesses
Mathematica Policy Research
The last decade has brought tremendous changes in the
health care system as payers and providers struggle to bring
health care expenditures under control. The momentum to achieve
a reformed, more managed U.S. health care system, one which
seeks to bring costs under control while improving access to,
continuity and coordination of care, appears unstoppable.
However, it remains unknown how this transforming health care
system will affect the health and well-being of people with
significant disabilities and chronic illnesses. The Medicare
program has lagged behind the private insurance market and even
the Medicaid program in the proportion of its beneficiaries
participating in managed care plans. In 1995, about 2.3 million
older persons out of a total Medicare beneficiary population of
25 million were enrolled in the Medicare Risk Program
implemented under TEFRA. There is little information on the
experience of older persons with disabilities in these and
other managed care plans.
The purpose of this study is to: (1) address the
characteristics of elderly persons with chronic illnesses and
disabilities that need to be accommodated in designing and
operating managed delivery systems (MDS); (2) examine the
issues that health care policy makers, plan administrators and
providers need to consider in designing, operating, and
monitoring MDS for the elderly with disabilities and chronic
illness; (3) examine how MDS actually perform in meeting the
needs of the elderly disabled; and (4) identify the factors
that influence the success of MDS in meeting the needs of this
population.
Funding: Total Award $349,450 (FY97 $244,450; FY00
$105,000)
End Date: May 31, 2001
Medical Expenditure Panel Survey (MEPS) Nursing Home Component
Medstat Group
The Office of the Assistant Secretary for Planning and
Evaluation (ASPE) and the Agency for Health Care Policy and
Research (AHCPR) entered into this Interagency Agreement for
the purpose of allowing ASPE and an ASPE contractor (The
MEDSTAT Group) access to the Nursing Home Component of the 1996
Medical Expenditure Panel Survey (MEPS) including the Community
Caregiver Supplement. Through its contractor, ASPE will edit
and prepare data files and analyze data from the MEPS Nursing
Home Component and the Community Caregiver Supplement. The
purpose of the ASPE-supported analyses is to better understand
how to promote and improve home and community-based services as
opposed to institutional services for persons with significant
functional disabilities.
End Date: July 1, 2000
Medicare Post-Acute Care: Quality Measurement
Urban Institute
This project developed four outcome measurement instruments
and methods of data collection that could be used in future
research to examine outcomes and costs associated with Medicare
post-acute care (PAC) services for patients who have suffered a
stroke, congestive heart failure(CHF), pneumonia, and back and
neck conditions. These conditions were selected because of
their prevalence within and across PAC settings. The
instruments and the data collection methodology will be revised
based on two field tests and technical expert input. The
outcome measurement instrument developed for stroke patients
will be used in other ASPE funded studies (i.e., A Comparative
Study of the Outcomes and Costs Associated with Medicare Post-
Acute Services).
Funding: Total Award $482,943 (FY97 $321,035; FY99
$161,908)
End Date: December 31, 2000
Monitoring the Health Outcomes for Disabled Medicare Beneficiaries
Laguna Research Associates
The Balanced Budget Act (BBA) of 1997 mandated major
changes in home health payment requiring the implementation of
a Prospective Payment System (PPS) by October 1999 (later
delayed until October 2000) and an Interim Payment System (IPS)
prior to the implementation of PPS. It also contained changes
in eligibility and coverage for home health services. These
changes, while intended to reduce Medicare home health costs,
run the risk of reducing beneficiaries' access to appropriate
care and adversely affecting health outcomes, especially for
beneficiaries needing the most care (Komisar and Feder 1998,
Smith and Rosenbaum 1998, MedPAC 1999, GAO 1998, Gage, 1998).
Disabled Medicare beneficiaries are especially vulnerable.
The purpose of this project is to study the impact of
recent payment policy changes on disabled Medicare
beneficiaries' satisfaction and quality of life with a view
toward formulating inferences that will inform national home
health care policy for the disabled. The study will build on a
research project recently funded by the Home Care Research
Initiative of The Robert Wood Johnson Foundation that examines
the direct and indirect effects of the BBA changes. The
project's main focus is to examine BBA impacts on Medicare
beneficiaries' access to care, costs, satisfaction, and quality
of care. Also examined will be the effects on agencies and on
the overall health system.
Funding: Total Award $150,000 (FY99 $150,000)
End Date: September 30, 2001
National Study of Assisted Living for the Frail Elderly
``Assisted living'' refers to residential settings for
people with disabilities which combine both housing and
personal assistance services within a homelike or
noninstitutional environment. The number of assisted facilities
nationally is not known; estimates range from 8,000 to 30,000.
Similarly, estimates for the number of frail elderly and other
persons residing in such facilities range from 350,000 to
1,000,000. This study will, among other things, generate a more
reliable estimate of the number of these facilities and their
residents. As assisted living options multiply, a challenge
facing the Federal and State governments is how to regulate
such arrangements, balancing consumer protection concerns
(especially if public funds reimburse costs) with resident
rights for self-direction, taking risks and maintaining
accustomed lifestyles.
The major purpose of this project is to analyze the role of
assisted living within the current long-term care system from
the perspective of consumers, owners/operators, workers,
regulators, investors and other stakeholders, and to issue a
report on its current status and future directions. The study
will address several broad policy-relevant issues, including
supply and demand trends; barriers; how closely practice
parallels philosophy; the impact of key features on outcomes;
and quality and accountability. The contractor will assist HHS
and other Federal agencies in the formulation of regulatory and
financing policy options for assisted living. A Technical
Advisory Group has been established to provide guidance to the
contractor.
Funding: Total Award $2,025,000 (FY98 $350,000; FY99
$75,000)
End Date: June 30, 2000
``Cash and Counseling'' Demonstration/Evaluation.
University of Maryland, Center on Aging
This project, which is being done in collaboration with the
Robert Wood Johnson Foundation, will employ a classical
experimental research design (i.e., random assignment of
participants to treatment and control groups) to test the
effects of ``cashing out'' Medicaid-funded personal assistance
services for the disabled. The demonstration will include
elderly as well as younger disabled consumers. Two States are
expected to participate in the demonstration. In these States,
control group members will receive ``traditional'' benefits--
i.e., case managed home and community-based services, where
payments for services are made to vendors--while treatment
group members receive a monthly cash payment in an amount
roughly equal to the cash value of the services they would have
received under the traditional program.
It is hypothesized that cash payments will foster greater
client autonomy and that, as a result, consumer satisfaction
will be greater. Consumers are expected to purchase a somewhat
different mix of disability-related services and/or assistive
technologies when they make the decisions and payments
themselves than when case managers contract with vendors on
their behalf. It is also hypothesized that States will save
Medicaid monies (mostly in administrative expenses) from
cashing out benefits. The analysis will consider the effects of
the demonstration according to the varying characteristics of
the consumers including age, disability, gender, family
support, and other factors.
Funding: Total Award $1,902,794 (FY97 $350,000; FY98
$111,389; FY99 $250,000; FY00 $191,405)
End Date: September 30, 2004
Synthesis and Analysis of Medicare Hospice Benefits
Urban Institute
The rapid rise in Medicare hospice expenditures,
particularly on behalf of nursing home residents, has drawn the
attention of a wide variety of health policy makers and the
Office of the Inspector General (OIG). In a recent study, the
OIG recommended ways to modify how Medicare and Medicaid pays
for hospice services. Most experts agree that, however, that a
larger study is needed to examine key hospice trends nationally
and in selected States. This current study will collect
additional information on the Medicare hospice benefit,
including trends in utilization and expenditures, who is
covered, and in which care settings. This information will help
inform health policy makers as they consider alternative
hospice benefit and payment designs.
End Date: April 1, 2000
Funding: Total Award $234,970.04 (FY97 $174,980.60; FY98
$59,989.44)
Synthesis and Analysis of Medicare Post-Acute Care Benefits and
Alternatives
Urban Institute
This two-part project synthesized what was known about: (a)
coverage and payment policies for post-acute care (PAC); (b)
predictors of PAC use and nonuse and of the type, amount, and
duration of PAC use; (c) PAC utilization including
characteristics of PAC patients, patterns of PAC utilization,
and geographic distribution of providers; (d) Medicare
expenditures during the course of PAC episodes; (e) outcomes of
patients in and across PAC settings; and (f) State policies
designed to maximize Medicare PAC coverage.
The first report, ``Medicare's Post-Acute Care Benefits:
Background, Trends, and Issues to be Faced'', provides
background on post-acute care expenditures and utilization, and
Medicare policy changes that have contributed to these trends;
the supply and changes in distribution of post-acute care
providers; beneficiary, provider, and market characteristics
associated with differential post-acute care provider use; and
issues that need to be addressed regarding Medicare post-acute
care services.
The second report, ``Interviews with Provider and Consumer
Groups, and Researchers and Policy Analysts'', summarizes
discussions with key stakeholders regarding issues with
Medicare's skilled nursing facility, home health,
rehabilitation and long-term care hospital benefits. Many
comments were raised regarding the impact of the changes
enacted in the Balanced Budget Act on these benefits.
Funding: Total Award $227,675.88 (FY97 $162,731; FY99
$64,944.88)
End Date: May 2000
The Contribution of Changes in Medication Use to Improvements in
Functioning among Older Adults
Philadelphia Geriatric Center
A possible explanation for the recently observed decline in
the prevalence of disability in the U.S. elderly population is
that better treatment of chronic diseases through medical
procedures and pharmaceuticals has led to an improvement in
functioning in the elderly population. Lending some credence to
this hypothesis is research by Freedman and Martin (forthcoming
in the American Journal of Public Health) that documents an
increase in the prevalence of chronic health conditions such as
arthritis, diabetes, stroke and heart disease during the same
period that disability has fallen. They hypothesize that
changes in the management of chronic disease--and changes in
medication use in particular--have caused chronic health
conditions to become less debilitating as their prevalence has
increased.
This project supplements an existing National Institute on
Aging. Under that grant, the role of changes in the use of
medications in explaining aggregate changes in functioning in
the U.S. population aged 51-61 will be examined. The data sets
for the analyses are the first (1992) and fourth (1998) waves
of the Health and Retirement Survey (HRS), which provide
nationally representative cross-sections of the
noninstitutionalized population in this age range.
Funding: Total Award $125,000 (FY00 $125,000)
End Date: September 30, 2001
CENTERS FOR DISEASE CONTROL AND PREVENTION
National Center for Chronic Disease Prevention and Health Promotion
CDC's National Center for Chronic Disease Prevention and
Health Promotion (NCCDPHP) is involved in a wide array of
chronic disease prevention and control activities on behalf of
older Americans. NCCDPHP programs include musculoskeletal
diseases (osteoarthritis, osteoporosis), cardiovascular health,
Alzheimer's disease, urinary incontinence, the health care and
long-term care needs of women and minorities, health status
surveillance, physical activity promotion, disability
prevention, diabetes management, cancer prevention and control,
oral health, and the elimination of health disparities. Each is
reviewed briefly below.
Arthritis
Arthritis and other musculoskeletal diseases are prevalent
and disabling chronic diseases, affecting approximately 38
million persons in the United States. Data indicate that 49.4
percent of persons 65 years and older have symptomatic
musculoskeletal diseases and 11.6 percent of persons in this
age group have arthritis as a major or contributing cause of
activity limitation. Data are needed to describe the natural
history of disease as well as to direct development of
effective intervention efforts. To address the burden of
arthritis, NCCDPHP:
widely disseminated the National Arthritis
Action Plan--A Public Health Strategy. This plan was
released in November of 1998 and was developed under
the leadership of CDC, the Arthritis Foundation, and
the Association of State and Territorial Health
Officials. The plan proposes action in three major
areas: surveillance, epidemiology, and prevention
research; communication and education; and programs,
policies, and systems. It is designed to encourage
public health organizations, arthritis organizations,
and other interested organizations to work together at
the national, state, and local levels.
analyzed the Arthritis Self-Help Course.
This analysis showed the course to be a cost-saving
intervention from both the societal and health care
system perspectives.
determined the prevalence of hip and knee
osteoarthritis among whites and blacks in Johnston
County, NC, a rural, southern county. The Johnston
County Osteoarthritis Project is beginning follow-up of
3200 Caucasian and African-American residents of a
rural North Carolina county to determine factors
associated with the development and progression of hip
and knee osteoarthritis--the leading causes of
arthritis disability.
Alzheimer's Disease
Chronic neurological diseases, conditions common among
elderly, causes high levels of morbidity, disability, family
stress, and economic burden. For example, the costs due to
dementias were estimated at $24-$48 billion in 1985, and will
increase as the population ages. However, the epidemiology of
these conditions is poorly understood. NCCDPHP is studying the
epidemiology of Alzheimer's Disease to determine disease rates,
risk factors, and prevention factors.
Health Care and Long-term Care Needs
The WISEWOMAN (Well-Integrated Screening and Evaluation for
Women in Massachusetts, Arizona, and North Carolina) program is
funded by NCCDPHP to determine whether adding other preventive
services such as cardiovascular disease risk factor screening
and intervention to the National Breast and Cervical Cancer
Early Detection Program is effective in improving the health
status of uninsured women age 50 and older.
NCCDPHP conducted an assessment of long-term care needs
among older adults in the Indian Health Service Santa Fe
Service Unit, New Mexico. The objectives of the project were
(1) to provide estimates of the population of functionally
dependent adults age 55 and over within the Santa Fe Service
Unit (SFSU) and distinguish clinically relevant subgroups; (2)
to document the extent of informal care provided by family
members to elders with chronic care needs; (3) to analyze the
strengths and weaknesses of the current formal long-term care
service system within the SFSU to accommodate the needs of the
target population.
NCCDPHP has initiated the EnPOWER project to improve
prevention services in older women in HMO's. The project aims
to enhance and promote preventive health services for older
women in a managed care setting.
Health Status Surveillance
NCCDPHP conducts surveillance of the health status of the
elderly. Projects include:
the publication of ``Surveillance for
Selected Public Health Indicators Affecting Older
Adults United States,'' Morbidity and Mortality Weekly
Report, December 17, 1999;
the assessment of the prevalence of
electroconvulsive therapy on older adults by age,
gender, and ethnicity;
the assurance of complete, timely, and
accurate cancer surveillance data at the state,
regional, and national levels;
the generation of national and state
estimates of the prevalence and incidence of diabetes,
the processes and outcomes of care, and the costs of
care in the Medicare population;
the use of several health-related quality-
of-life measures in the state-based Behavioral Risk
Factor Surveillance System (BRFSS) to track quality of
life in the States; and
determination of the feasibility of a
Medicare claims-based surveillance system for possible
adverse effects of folic acid food fortification among
persons with vitamin B12 deficiency.
Cancer
More than 30 percent of deaths from breast cancer in women
over age 50 are preventable through widespread use of
mammography screening for early detection. The National Breast
and Cervical Cancer Early Detection Program targets underserved
women, including older women with low income, and women of
racial and ethnic minority groups. NCCDPHP currently funds the
50 states, 4 U.S. territories, the District of Columbia, and 15
American Indian/Alaska Native organizations through this
program.
NCCDPHP supports a project to generate information about
attitudes towards prostate cancer screening and treatment. The
project investigates (1) how quality of life is related to
early detection and treatment; (2) whether screening for
prostate cancer actually reduces mortality; and (3) the
development of appropriate health messages for men and their
families about prostate cancer screening and early detection.
NCCDPHP sponsors a program promoting the early detection of
colorectal cancer. The objectives of the project are (1) to
promote awareness and use of colorectal cancer screening among
health care providers and the public, especially the older
population; (2) to support research that promotes the inclusion
of colorectal cancer screening in quality measures applied to
managed care organizations; and (3) to support the development
of standards for screening sigmoidoscopy.
Cardiovascular Health
Recognizing the immense burden of CVD, in FY1998, Congress
made available funding to initiate a national, state-based CVD
prevention program, starting with eight states, and in FY1999
to expanded to eleven states. In FY2000, CDC will spend more
than $25 million for the prevention and control of CVD and its
disabling conditions. These activities include:
Funding 5-6 additional states to implement
CVD prevention and control programs with environmental
interventions and policy strategies.
Assisting states to better measure the
burden of CVD, monitor progress in reducing risk
behaviors, and determine the economic cost of the
disease.
Funding state programs and research that
address racial and ethnic disparities in CVD.
Enhancing CDC's National Standards
Laboratory to improve state laboratory capacity and
tailor screening procedures for youth, elderly and
minority populations.
While strategies for preventing CVD (lipid management,
hypertension control, diabetes awareness, smoking cessation,
dietary modification, and physical activity behavior) exist,
more efficient and practical methods for reaching low-income
women and making prevention services available to them are
needed. The NCCDPHP is collaborating with the University of
North Carolina Prevention Center to produce a monograph that
describes appropriate research and programmatic methods and
protocols for integrating cardiovascular disease screening,
intervention, and evaluation programs aimed at financially
disadvantaged women. This monograph will include
recommendations for laboratory tests, clinical measurements,
interviews and surveys, field procedures, program tracking
systems, and analytic plans. It will include practical examples
of how to integrate CVD screening and intervention into
existing health service programs that come from the experience
of the WISEWOMAN (Well Integrated Screening and Evaluation for
Women) projects in North Carolina, Massachusetts, and Arizona.
This monograph will be written as a practical guide for state
and local health departments for use in designing and adapting
their own integrated prevention programs.
Diabetes
The burden of diabetes is heavier among elderly Americans.
More than 18 percent of adults over age 65 have diabetes.
NCCDPHP funds diabetes control programs (DCP) in all 50 states,
the District of Columbia, and eight U.S. affiliated island
jurisdictions to effect changes and improvements in systems
that care for and support people with diabetes. The primary
goal of the DCPs is to improve access to affordable, high-
quality diabetes care and services. Priority is on reaching
high-risk and disproportionately burdened populations which
include the aged. NCCDPHP provides resources and technical
assistance to state-based diabetes control programs to:
determine the size and nature of diabetes-
related problems and why they exist,
develop and evaluate new strategies for
diabetes prevention,
establish partnerships to prevent diabetes
problems,
increase awareness of diabetes prevention
and control opportunities among the public, the health
care and business communities, and people with
diabetes, and
improve access to quality diabetes care to
prevent, detect, and treat diabetes complications.
Oral Health
In the United States, 30,000 new cases of oral and
pharyngeal cancer will be diagnosed this year, and more than
8,000 people will die of these largely preventable cancers.
About 1 in 3 adults has untreated tooth decay and 25 percent of
adults older than 65 years have lost all of their teeth. Only
about half of people with diagnosed oral or pharyngeal cancer
survive more than 5 years; among African American men, only
about a third survive. People who do survive are at increased
risk of developing additional cancers and frequently have the
physical and psychological scars of what is one of the most
disfiguring of all cancers.
CDC is working with a consortium of public- and private-
sector organizations to develop a national program to prevent
oral and pharyngeal cancers and to promote early detection and
treatment, which can improve long-term survival. With its
partners, CDC is also working to promote cessation of tobacco
use, which especially when combined with heavy alcohol use is
the major risk factor for more than 75 percent of oral and
pharyngeal cancers in the United States.
CDC is also working to
Enhance surveillance of oral diseases using
state- and community-based data
Support water fluoridation through
surveillance, training, and quality assurance
Influence oral health policy and practice by
developing and distributing guidelines based on sound
science, e.g., infection control, fluoride use
Develop a national alliance of partners to
prevent and control oral cancer
Train dental and public health professionals
through residency and fellowship programs
Elimination of Health Disparities
Chronic diseases disproportionately affect racial and
ethnic minority populations in the U.S. The leading causes of
death and disability (such as cardiovascular disease) are
dramatically higher among these populations. Rates of death
from stroke are 60 percent higher among African Americans than
among whites. The prevalence in diabetes is higher among every
racial and ethnic minority compared to whites of similar age.
Among persons 65 years of age or older with one or more
physician visits in the past year, influenza and pneumococcal
vaccination levels among African Americans and Hispanics are
substantially lower than those of whites. Death rates due to
cancers, such as prostate and breast, are often higher among
minorities as well.
NCCDPHP administers the Racial and Ethnic Approaches to
Community Health Program (REACH 2010), a major part of the
President's Initiative on Race. The goal of this program is to
eliminate disparities in health status experienced by racial
minority and ethnic populations in key health areas (including
cardiovascular disease, diabetes, and immunizations) by the
year 2010. REACH demonstration projects are two-phase projects
through which communities mobilize and organize their resources
in support of effective and sustainable programs that will
eliminate the health disparities of racial and ethnic
minorities. These demonstrations require collaboration of both
program and research experts for the purpose of identifying
and/or developing successful community-based disease prevention
and health promotion models that can be replicated for the
ultimate goal of eliminating health disparities among racial
and ethnic minorities. In Phase I, REACH communities are
granted 12 months to develop a Community Action Plan (CAP).
Phase II communities are granted four additional years of
funding to implement and evaluate the CAP. Thirty-two community
coalitions were funded in FY1999. The California Endowment
contributed funding to support three additional organizations
in the state of California identified through CDC's competitive
process. In FY2000, 24 Phase II and 14 new Phase I communities
were funded.
Through an inter-agency agreement, NCCDPHP provided $1
million to the Administration on Aging (AoA) to fund four
demonstration projects focusing on health disparities among
older racial and ethnic minority populations. In addition to
the four projects funded directly by the AoA, other REACH 2010
communities include activities that impact aging populations as
well. Elderly-specific projects were:
Boston Public Health Commission was funded
to address cardiovascular disease (CVD), diabetes, and
immunization in elderly African American communities.
The Latino Education Project, Inc. was
funded to address CVD and late-stage diabetes among
rural and urban elders of Hispanic decent.
Special Services for Groups, Inc. was funded
to lead six community coalitions to address CVH,
diabetes, and immunization disparities among
individuals of Southeast Asian decent.
National Indian Council on Aging, Inc. was
funded to lead a community coalition focused on Indian
and Alaska native elders in nine states.
NCCDPHP funding will support Phase I of demonstration
projects. These projects serve as the foundation for Phase II
projects. The AoA is responsible for funding Phase II of REACH
2010 contingent upon availability of funds.
Cardiovascular disease (CVD) continues to be the leading
cause of death in the United States for women. African-American
women are at particular risk, with coronary heat disease (CHD)
and mortality rates 35.3 percent higher and stroke rates 71.4
percent higher than for white women. Low socioeconomic status
(SES) is also associated with higher CVD incidence and
mortality. NCCDPHP is collaborating with the University of
Alabama at Birmingham Prevention Research Center to produce the
``Women's Wellness Sourcebook Module III Heart Disease and
Stroke''. The Sourcebook is a culturally-appropriate training
curriculum designed to promote CVD prevention among low SES
minority women by teaching Community Health Advisors (CHAs) to
conduct risk-reduction counseling.
The Johns Hopkins University Prevention Research Center, in
partnership with the NCCDPHP, is exploring how church-based
programs in Baltimore can help prevent or control chronic
diseases. Program components include weight control and
nutrition, exercise and fitness, and smoking cessation, offered
in the church by trained lay leaders; interwoven with the
spiritual life and activities of the church, such as prayer
groups, sermons, testimony, choir practice, and meals.
The St. Louis University Prevention Research Center,
another NCCDPHP-supported center, has collected and analyzed
determinants of physical activity among 3,000 US women aged 40
to 75 years, including 600 each from the following subgroups:
African-American, Asian/Pacific Islander, American Indian/
Alaska Native, Hispanic,White, and low education (high school
or less).
Disability Prevention and Health Promotion
NCCDPHP is collaborating with the AARP, the American
College of Sports Medicine, the American Geriatrics Society,
the National Institute on Aging, and The Robert Wood Johnson
Foundation to create a ``National Plan to Increase Physical
Activity Among Adults Aged 50 and Older.'' These partners
hosted the ``Blueprint Conference'' on physical activity
promotion in Washington, DC on October 30-31, 2000.
NCCDPHP funds the Center for Health Promotion in Older
Adults at the University of Washington at Seattle, School of
Public Health to promote health among men and women aged 65
years or older. The Center evaluates the presence of social
networks and the influence of healthy eating and physical
activity on elderly residents of public housing units. The
Center also focuses on reducing disability and falls in older
adults through interventions to improve physical activity,
nutrition, and home safety.
NCCDPHP is collaborating with the Administration on Aging
(AOA) on a review of AOA's state and territorial aging agency
health promotion programs.
NCCDPHP is collaborating with the Association of State and
Territorial Chronic Disease Program Directors to document
chronic disease prevention and control program activities
within state and territorial health departments.
NCCDPHP released a monograph on quality of life and
indicators of healthy days at the 15th National Conference on
Chronic Disease Prevention and Control, November 29, 2000, in
Washington, DC.
NCCDPHP's Office on Smoking and Health provides web-based
educational materials for people who want to quit smoking and
for clinicians who want to help them. For older adults,
quitting smoking is one of the most important health actions
they can take. Materials include:
You Can Quit Smoking
Don't Let Another Year Go Up In Smoke: Quit
Tips
Treating Tobacco Use and Dependence: A
Clinical Practice Guideline, Public Health Service
NCCDPHP is studying the cost-effectiveness of different
interventions designed to prevent osteoporosis in women who are
perimenopausal or postmenopausal.
The Health Promotion and Education Database and Cancer
Prevention and Control Database contain aging-related health
information useful for health care providers and program
planners in state health and aging agencies. The databases
include literature and programmatic information about disease
prevention, health promotion, and health education information
on nutrition, smoking cessation, cholesterol, high blood
pressure, injury prevention, exercise, weight management,
stress management, diabetes mellitus, and breast and cervical
cancer screening. They are available through CDC's CDP (Chronic
Disease Prevention) File CD-ROM, the Public Health Service's
Combined Health Information Database (CHID) and CDC's WONDER
system. CDP File is available from the Superintendent of
Documents, Government Printing Office, Washington, DC 20402,
202-512-1800 (Stock No. 717-145-00000-3). CHID can be accessed
through most library and information services. CHID may be
accessed via the Internet at http://chid.nih.gov. For more
information about WONDER, contact CDC WONDER Customer Support
at 404-332-4569.
National Center for Environmental Health
CDC's National Center for Environmental Health (NCEH)
addresses the prevention of secondary conditions and promotion
of health among the 54 million Americans with disabilities. The
Center is analyzing NHIS and NHIS-Supplement on Aging data to
identify the correlates of aging related to sensory impairments
and to characterize disability in the above 55 age groups by
race/ethnicity, gender, region, and activity limitation. These
analyses will be included in the disability chapter of the
upcoming MMWR Supplement on Aging.
The NCEH environmental health laboratory is working to
improve measurement of biochemical markers of bone loss to help
physicians threat people with osteoporosis. The currently
accepted gold standard for measuring bone status is a bone
density test. However, such tests can only be repeated every 1-
2 years. The biochemical marker tests for bone loss can be
performed more frequently to assess the success of treatments
for osteoporosis.
The NCEH environmental health laboratory also is
collaborating on the Age-Related Eye Disease Study conducted by
the National Eye Institute. The laboratory is testing patients
participating in the study for levels of vitamins A, C, and E,
carotenoids, retinyl esters, lipids, zinc, and copper. The
laboratory is also assisting with genetic testings as part of
this study.
National Center for Health Statistics
CDC's National Center for Health Statistics (NCHS) is the
Federal Government's principal health statistics agency. The
NCHS data systems address the full spectrum of concerns in the
health field from birth to death, including overall health
status, morbidity and disability, risk factors, and health care
utilization.
The Center maintains over a dozen surveys and vital
statistics data files that collect health information through
personal interviews, physical examination and laboratory
testing, administrative records, and other means. These data
systems, and the analyses that result are designed to provide
information useful to a variety of policy makers and
researchers. NCHS frequently responds to requests for special
analyses of data that have already been collected and solicits
broad input from the health community in the design and
development of its surveys.
A broad range of data on the aging of the population and
the resulting impact on health status and the use of health
care are produced from these systems. For example, NCHS data
have documented the continuing rise in life expectancy and
trends in mortality that are essential to making population
projections. Data are collected on the extent and nature of
disability and impairment, limitations on functional ability,
and the use of special aids. Surveys currently examine the use
of hospitals, nursing homes, physicians' offices, home health
care and hospice, and are being expanded to cover hospital
emergency rooms and surgi-centers.
In addition to NCHS surveys of the overall population that
produce information about the health of older Americans, a
number of activities provide special emphasis on the aging.
They are described below.
The Second Longitudinal Study of Aging
The Second Longitudinal Study of Aging (LSOA II) is a
collaborative project of the National Center for Health
Statistics and the National Institute on Aging. This
prospective survey consists of a baseline interview, called the
Second Supplement on Aging (SOA II), and two followup
interviews fielded at two-year intervals. The SOA II interviews
were conducted with a nationally representative sample of 9,447
civilian noninstitutionalized Americans 70 years of age and
over. It was fielded as part of the 1994 National Health
Interview Survey and interviews were collected in-person
between 1994 and 1996. The two reinterviews were administered
by phone with these sample persons and have now been completed,
one in 1997-1998 and one in 1999-2000.
The LSOA II is designed primarily to measure changes in the
health, functional status, living arrangements, and health
services utilization of older Americans as they move into and
through the oldest ages. Secondarily, the objective of the
study is to provide a mechanism for monitoring the impact of
proposed changes in Medicare and Medicaid and the accelerating
shift towards managed care on the health status of the elderly
and their patterns of health care consumption. Finally, the
LSOA II replicates the first Longitudinal Study of Aging which
was conducted ten years earlier between 1984 and 1990. To this
end, questions concerning physical functioning and health
status and their correlates which were part of the first LSOA
are repeated in the LSOA II. These include questions on
activities of daily living, instrumental activities of daily
living, and work-related activities, as well as medical
conditions and impairments, family structure and relationships,
and social and community support. In addition to these repeated
items, the LSOA II questionnaire was been expanded to include
information on risk factors (including tobacco and alcohol
use), additional detail on both informal and formal support
services, and questions concerning the use of prescription
medications.
The SOA II microdata were released to the public in 1998.
The first followup is expected to be released in 2001 and the
second follow up in 2003. These data, when used in conjunction
with data from the LSOA, enable researchers to identify changes
in functional status, health care needs, living arrangements,
social support, and other important aspects of life across two
cohorts with different life course perspectives. This will
provide those who use the data with an opportunity to examine
trends and determinants of ``healthy aging.'' Users of the LSOA
and LSOA II data have typically consisted of researchers, both
those in the Federal government and in university settings,
policy planners, and agencies and organizations serving older
persons.
Health, United States, 1999 Health and Aging Chartbook
In October 1999, the Health, United States, 1999 Health and
Aging Chartbook was published. This special study on health and
aging was part of the annual report on the nation's health
submitted by the Secretary of the U.S. Department of Health and
Human Services to the President and Congress. In 34 figures and
accompanying text, it summarizes the health of older people in
the United States at the end of the twentieth century, using
nationally representative health surveys and vital statistics.
Measures of health status, including mortality, the prevalence
of chronic conditions, disability, oral health, hearing and
visual impairments are presented in the volume. In addition,
health care access and utilization measures such as hospital
discharge rates, use of home health care services, and health
insurance coverage are included. Special attention is paid to
differences in health by age, sex, and race and ethnicity. The
chartbook was distributed to all members of Congress and
highlighted in a Congressional briefing sponsored by Senator
Mikulski and Representative Hoyer.
Trends in Health and Aging
Trends in Health and Aging is a major data dissemination
project funded in part by the National Institute on Aging and
located within NCHS's Office of Analysis, Epidemiology, and
Health Promotion (OAEHP). Trends in Health and Aging draws upon
the statistical resources of NCHS and other Federal statistical
agencies to provide up-to-date information on health behaviors,
health status, utilization and cost of care for the older
population in the United States.
Trends in Health and Aging Data Warehouse
The core of the project is the Trends in Health and Aging
Data Warehouse (DWHA). DWHA is intended for use by policy and
program analysts, researchers and the general public. DWHA
contains information from NCHS surveys and other data systems
in a format easily accessible to users. The list of topics and
measures grows based on users' suggestions and the data are
updated as soon as new figures become available. The data
warehouse became available to the public on the Internet in
November 1999. It can be accessed at the following address:
http://www.cdc.gov/nchs/agingact.htm. It serves as an important
electronic resource for those seeking relevant national data on
a host of issues related to future access to affordable health
care and the enhancement of quality of life.
In the DWHA trend data on the elderly population in the
United States is organized under six general topic areas:
demography (or population composition), vital statistics,
health status and well-being, risk factors and health behavior,
health care utilization, and health care expenditure.
The target population is persons of 65 years of age and
older, but the majority of the tables also contain data on 45-
64 year olds for comparison purposes and for representation of
the baby boom generation. The indicators are presented by 5- or
10- year age groups. Open-age intervals (for example, 65 and
over) can be seen in a crude and age-adjusted form. Usually,
for age adjustment the year 2000 standard residential
population of the United States was used.
The data are aggregated in interactive tables developed
using a user-friendly dissemination tool, Beyond20/20. Tables
prepared in Beyond20/20 are capable of presenting the data in
the form of charts and maps by the exact variables needed by
the user, and the data from the table can be extracted in
formats acceptable by most software packages.
Each table displays the selected measure(s) by sex, age
interval, race or Hispanic origin for as many years as the data
from the particular data system are available. Where possible,
the tables present the information by States. Metadata
accompanying each table provide important information on data
sources, statistical methods used to get the information, and
references to corresponding publications and supporting
Internet sites.
Examples of selected tables are as follows:
Demography (population composition)
Population (number and percent of people, national and
state estimates)
Vital Statistics
Life Expectancy
Mortality (national and state estimates)
Living Arrangements
Health Status and Well-Being
Self-assessed health
Functional status of older adults
Functional limitation
Total tooth loss
Mental health status of nursing home residents
Selected chronic conditions
Risk Factors
Immunization
Current cigarette smoking
Obesity
Exercise
Health Care Utilization
Nursing home use
Hospital discharges
All-listed procedures for hospital inpatients
Several special web-based reports based on data from DWHA
have been written and will be posted to the web site and
available in hard-copy formats. The topics include trends in
elderly mortality, oral health of older Americans, trends in
vision and hearing, and trends in nursing home use.
Federal Forum on Aging-Related Statistics
The Forum was initially established in 1986, with the goal
of bringing together Federal agencies with a common interest in
database development and statistical compilation on issues in
aging. The Forum has played a key role in improving aging-
related data by critically evaluating existing data resources
and limitations, stimulating new database development,
encouraging cooperation and data sharing among Federal
agencies, and preparing collaborative statistical reports.
During 1998, an organizing committee was established to
coordinate the activities and goals of the Forum for 1999 and
beyond. In addition to the Bureau of the Census, the National
Center for Health Statistics, and the National Institute on
Aging--the original core agencies--the members now include
representatives from the Administration on Aging, the Bureau of
Labor Statistics, the Health Care Financing Administration, the
Office of Management and Budget, the Office of the Assistant
Secretary for Planning and Evaluation, and the Social Security
Administration.
On August 10, 2000, the Federal Interagency Forum on Aging-
Related Statistics (Forum) released ``Older Americans 2000: Key
Indicators of Well-Being.'' As one of the core members of the
Forum, NCHS took the lead in producing, promoting, and
disseminating this well received report. The report included 31
key indicators carefully selected by the Forum to portray
aspects of the lives of older Americans and their families. The
report is divided into five subject areas: population,
economics, health status, health risks and behaviors, and
health care. The report can be accessed via the Forum's Web
Site--http://www.agingstats.gov.
NHANES I Epidemiologic Follow-Up Study
The first National Health and Nutrition Examination Survey
(NHANES I) was conducted during the period 1971-75. The NHANES
I Epidemiologic Follow-up Study (NHEFS) tracks and re-
interviews the 14,407 participants who were 25-74 years of age
when first examined in NHANES I. NHEFS was designed to
investigate the relationships between clinical, nutritional,
and behavioral factors assessed at baseline (NHANES I) and
subsequent morbidity, mortality, and hospital utilization, as
well as changes in risk factors, functional limitation, and
institutionalization.
The NHEFS cohort includes the 14,407 persons 25 74 years of
age who completed a medical examination at NHANES I. A series
of four follow-up studies have been conducted to date. The
first wave of data collection was conducted from 1982 through
1984 for all members of the NHEFS cohort. Interviews were
conducted in person and included blood pressure and weight
measurements. Continued follow-ups of the NHEFS population were
conducted by telephone in 1986 (limited to persons age 55 and
over at baseline), 1987, and 1992.
Participant tracing and data collection rates in the NHEFS
have been very high. Ninety-six percent of the study population
has been successfully traced at some point through the 1992
follow-up. While persons examined in NHANES I were all under
age 75 at baseline, by 1992 more than 4,000 of the NHEFS
subjects had reached age 75, providing a valuable group for
examining the aging process. Public use data tapes are
available from the National Technical Information Service for
all four waves of follow-up. The 1992 NHEFS public use data is
also available via the Internet. NHEFS data tapes contain
information on vital and tracing status, subject and proxy
interviews, health care facility stays in hospitals and nursing
homes, and mortality data from death certificates. All NHEFS
Public Use Data can be linked to the NHANES I Public Use Data.
NHANES IV Planning
The Fourth National Health and Nutrition Examination Survey
began field operations in April of 1999. Although a wide range
of the conditions assessed in NHANES IV are most common among
the elderly, several components are particularly relevant to
aging research:
Muscle Strength, Impairment, and Disability:
All persons age 50+ will have measurement of isokinetic
muscle strength of knee extensors and flexors and all
persons age 60+ will have an assessment of ability and
time to get up from an armless chair five times and
time to perform a twenty foot walk at the usual speed.
Both sets of measures will provide important data on
physical impairment and function in the elderly and
will be correlated to other disability related self
reported items and other objective measurements
obtained in the survey.
Lower Extremity Disease: For the first time,
the survey includes an evaluation of lower extremity
disease in persons age 40+, including Ankle-Brachial
Pressure Index measurement and assessment of peripheral
neuropathy. These data are especially important for
assessing the complications of diabetes and the
prevalence of peripheral vascular disease.
Visual and Hearing Impairment: Vision (age
12+) and hearing (age 20+) are being assessed including
assessment of visual acuity, near vision (age 50+),
pure tone audiometry thresholds, and typanometry.
Sensory impairment is an important component of
functional impairment in the elderly.
Bone Mineral Status: Bone mineral status is
being assessed including total bone mineral content and
bone mineral density by dual X-ray absorptiometry.
Osteoporosis is an important risk factor for hip
fractures in the elderly.
Cognitive Function: Cognitive function is
being assessed in persons age 60+ with the Digit Symbol
Substitution Test.
Balance and Vestibular Function: The
standard Romberg test of postural sway is being
assessed in all persons age 20+. Balance impairment is
related to the incidence of many fractures caused by
falling, especially hip fractures in the elderly.
Analysis of NHANES III Data
NCHS is engaged in a range of projects analyzing data from
NHANES III related to aging. These projects include:
Prevalence of Disability and Risk Factors
Associated with Disability. NHANES III data will be
analyzed to assess the prevalence of physical and
functional limitation. It includes self reported data
obtained in the household interview and performance-
based data obtained in the mobile examination center.
The risk factors associated with disability will be
assessed to provide a better understanding of the
etiology and treatment of disability in the elderly.
Region of Birth and Cardiovascular Risk
Factors. NHANES III data will be used to assess early-
life influences such as region of birth on the pattern
of risk factors for cardiovascular disease in later
life.
Nutritional Intake among the Elderly. The
patterns of nutrient intake among adults age 60+ in
NHANES III will be analyzed.
Vital Statistics on Aging
Information on mortality from the national vital statistics
system plays an important role in describing and monitoring the
health of both the institutionalized and non-institutionalized
elderly population. The data include measures of life
expectancy, causes of death, and age-specific death rate
trends. The basis of the data is information from death
certificates, completed by physicians, medical examiners,
coroners, and funeral directors, used in combination with
population information from the U.S. Bureau of the Census.
Effective with mortality data for 1997, additional detail
on the aging population was included in the official national
life tables. For the first time life expectancy and other life
table values for the population aged 85 to 100 years were shown
in the annual life tables by incorporating information from the
Medicare program on the mortality experience of the aged
population with standard information from the vital statistics
system.
NCHS is expanding outreach to certifying physicians on
proper completion of the cause-of-death section of the death
certificate by designing material appropriate for diverse
settings including professional meetings and electronic death
certificates.
Effective with mortality data for 1999, two important
changes are being implemented for state and national mortality
statistics: (1) causes of death are coded and classified by the
Tenth Revision of the International Classification of Diseases
(ICD-10), replacing ICD-9, which was used by the U.S. during
1979-1998; and (2) the standard population used for age-
adjusting death rates is changed from 1940 to the year 2000
population. The 1940 standard has been used for about 50 years.
Use of ICD-10 affects the comparability of cause-of-death
trends over time; the extent of the discontinuities is measured
using a Comparability Study, results of which will be available
at the time the 1999 mortality data are published in early
2001. The new population standard for age-adjusting death rates
affects the absolute level of death rates for many causes of
death, in particular, deaths from chronic diseases; it also
affects the relationship of mortality among the race groups.
NCHS publications describe the extent and implications of these
changes.
The National Health Care Survey
The National Health Care Survey (NHCS) is an integrated
family of surveys conducted by the NCHS to provide annual
national data describing the Nation's use of health care
services in ambulatory, hospital and long-term care settings.
Currently, the NHCS includes six national probability sample
surveys and one inventory. These seven data collection
activities include:
the National Hospital Discharge Survey which
examines discharges from non-Federal, short-stay and
general hospitals;
the National Survey of Ambulatory Surgery
which examines visits to hospital-based and
freestanding ambulatory surgery centers;
the National Ambulatory Medical Care Survey
which examines office visits to non-Federal, office-
based physicians;
the National Hospital Ambulatory Medical
Care Survey which examines visits to emergency and
outpatient departments of non-Federal, short-stay and
general hospitals;
the National Health Provider Inventory which
is a national listing of nursing homes, hospices, home
health agencies and licensed residential care
facilities;
the National Home and Hospice Care Survey;
and
the National Nursing Home Survey.
Improving Self-Reports of Health Status by the Elderly
The National Laboratory for Collaborative Research in
Cognition and Survey Measurement of NCHS has conducted several
cognitive research projects with elderly respondents. In 1998,
Lab staff continued their investigation of recall and judgment
issues that elderly respondents may have when answering
questions regarding health status and quality of life. This
project involved both in-house and extramural research. In-
house research is conducted by recruiting subjects to the NCHS
Questionnaire Design Research Laboratory. Extramural research
is conducted by the University of Maryland's Survey Research
Center using split-ballot field experiments.
National Immunization Program
CDC's National Immunization Program provides medical and
epidemiologic expertise and collaborates with other CDC
organizations and HHS agencies in developing strategies to
enhance immunization coverage of adults, including influenza,
pneumococcal, hepatitis B, measles, mumps, rubella, and
varicella vaccines and combined tetanus and diphtheria toxoids.
One of the greatest challenges we face is extending the success
in immunization with children to the adult population.
Immunization rates for influenza and pneumococcal disease
are at record highs in persons 65 years of age or older. The
Healthy People 2000 Objective for influenza vaccination in this
age group has been achieved. It is estimated that in 1996-1997,
about 19,500 deaths were prevented by influenza vaccination in
persons in persons 65 years or older. In addition, increased
use of pneumococcal vaccine between 1993 and 1997 saved almost
$27 million in hospital costs alone.
In spite of the progress that has been made, adult vaccines
continue to be underutilized. Reasons for this include: 1)
limited appreciation of the impact of adult vaccine-preventable
diseases and missed opportunities to vaccinate during contacts
with health-care providers; 2) failure to organize programs in
medical settings that ensure adults are offered the vaccines
they need; 3) doubts about the safety and efficacy of adult
vaccines; 4) selective rather than universal approaches to
vaccination; and 5) inadequate reimbursement for adult
vaccination services.
To overcome these challenges, CDC has taken a number of
steps including:
Testing Vaccine Safety and Effectiveness
CDC is actively engaged in determining vaccine
effectiveness. CDC and three health plans assessed the
effectiveness of influenza vaccine in patients age 65 or older
in preventing hospitalizations and deaths. Results showed that
vaccination prevented 18-24 percent of the hospitalizations for
pneumonia and 35-61 percent of all deaths. These findings
support the concept that health plans should cover influenza
vaccination, as well as actively promote the vaccine each fall.
In January of 1999, CDC and others published a study on the
safety of pneumococcal vaccination in the Journal of the
American Medical Association, ``The Safety of Revaccination
with Pneumococcal Polysaccharide Vaccine.''
Education and Training
Enhancing education and training is a priority in adult
vaccination efforts. CDC aired the first national video-
conference on adult immunization technical issues in June 1998
and rebroadcast the presentation in June 1999. It was also
broadcast in Spanish, with special efforts to promote it in all
of the boarder states, Mexico, and the Caribbean.
CDC and the Association of Teachers of Preventive Medicine
developed and tested the ``What Works'' interactive software
(CD ROM) program targeted at private primary care providers who
provide health care services primarily for adults. This program
focuses on strategies to increase immunization coverage levels
among adults and technical issues relating to adult
vaccinations.
Immunization teaching materials for physicians were
developed through a collaboration with CDC, Association of
Teachers of Preventive Medicine, and the Department of Family
Medicine at the University of Pittsburgh. The training
materials are designed to be used by medical schools for
students and residents. These products were published between
April 1998 and April 1999 and include a Facilitators Guide, a
Small Group Booklet, and a Reference Booklet.
Two large print booklets were designed in 1999 to be
distributed by health care providers to adult and senior
patients. The focus of the booklets is to empower adults and
seniors to take action for their own health. The vaccines
presented include all immunizations important for adults of all
ages. With the senior book emphasizing the vaccines for those
diseases that can cause the most serious problems, i.e.,
influenza, pneumococcal disease, and adult tetanus and
diphtheria among the elderly.
Recommendations
CDC worked with the National Medical Association to develop
a consensus document ``Adult Immunizations: Increasing
Immunization Rates among African-American Adults'' published in
1999. The document clearly demonstrates the need for improving
vaccination in African-American adults and offers
recommendations on how to do so.
Task Force for Community Preventive Services included
recommendations about successful interventions to increase
coverage among adults in the published Guide to Community
Preventive Services.
The National Vaccine Advisory Committee and CDC published
recommendations for vaccination of adults in non-traditional
sites in the March 24, 2000 MMWR.
Revision of Standards for Adult Immunization Practices,
which were first developed in 1990, are under way. Revision
began in 2000 and will be completed by December of 2001.
The guide, ``Prevention and Control of Vaccine-Preventable
Disease in Long-Term Care Facilities,'' was published in the
September/October 2000 issue of the Journal of the American
Medical Directors Association, and widely disseminated by CDC
and HCFA to state health departments and nursing home
directors.
Authors from CDC published an article, ``Vaccine
recommendations for Patients on Chronic Dialysis,'' in the
March/ April 2000 issue of Seminars on Dialysis.
Standing Orders
Dissemination of guidelines for health care providers is
another important activity. CDC, in collaboration with the
Advisory Committee on Immunization Practices and the Health
Care Financing Administration, has recommended a key strategy
called ``standing orders'' to improve influenza and
pneumococcal vaccination levels in nursing homes throughout the
country. A standing order enables nursing homes to provides
these vaccinations to nursing home residents without an
individual prescription.
A project started in July of 1999 to evaluate the
effectiveness of standing order programs to improve
pneumococcal and influenza vaccination rates in nursing homes.
It is a multi-state project (9 intervention, 5 control) to
develop, implement and evaluate standing order programs and
other immunization programs for influenza and pneumococcal
vaccination among seniors in nursing homes funded by CDC 1
percent Evaluation funds and the National Vaccine Program
Office. It is run in collaboration with HCFA and Peer Review
Organization (PRO).
Delivering Vaccines to Adults
Since 1997, CDC immunization grant guidance has instructed
grantees to assign at least 0.5 FTE to coordinate adult
immunization activities; in CY 2000, 35 states reported having
at least 0.5 FTE designated for this purpose. CDC has an annual
influenza vaccine contract which many states use to purchase
influenza vaccine for use by the state or local health
departments. In 2000, CDC negotiated contracts for 2 million
doses of influenza vaccine. Over 90 percent of local health
departments deliver influenza vaccine, 85 percent deliver
tetanus toxoid, 77 percent deliver hepatitis B vaccine, and 48
percent deliver pneumococcal vaccine. Since 1997, CDC has
conducted the Life Preserver campaign in collaboration with
state health departments, to promote influenza and pneumococcal
vaccination among persons with diabetes.
Understanding Gaps
CDC commissioned an Institutes of Medicine (IOM) Report on
the financing of vaccines. Calling the Shots: Immunization
Policies and Practices found that ``additional funds are needed
to purchase vaccines for uninsured and undersinsured adult
populations within the states.'' Work is now being done to
implement and respond to the recommendations.
CDC also conducts research to better understand and improve
adult vaccine delivery, including:
Reviewing adult immunization activities in
the state immunization programs, 1997-99, to determine
best practices.
Tested AFIX (Assessment, Feedback,
Incentive, and eXchange) methods, very successful for
childhood immunization, for physicians of Medicare
beneficiaries in New Jersey.
Surveying African American physicians to
identify barriers to delivery of adult immunization,
and will use the results to design and evaluate a
provider-based intervention to improve vaccination
services.
Designing and evaluating a multi-component
intervention in New Jersey to improve the use of
influenza and pneumococcal vaccination and cancer
screening (mammography and Pap testing) among African
American women enrolled in Medicare.
Improved Monitoring of Coverage
Influenza and pneumococcal vaccination status is asked
annually on the NHIS. In 1999, the BRFSS added a question on
the type of place where influenza vaccination was received.
Additionally, CDC has recommended standardization of
pneumococcal vaccination questions in all relevant surveys
(NHIS, BRFSS, HCFA's Medicare Current Beneficiary Survey).
Hepatitis B vaccination status will be included on the 2000
NHIS. CDC also worked with three HMO's to evaluate the
feasibility of including a measure of pneumococcal vaccination
among persons 65 years of age and older on HEDIS. Based on the
results of this work, the measure has been approved for
addition to HEDIS. CDC is also developing software suitable for
assessing vaccination levels in adult patient practice
settings.
2000-2001 Influenza Season
The influenza season of 2000-2001 has posed new challenges
to immunization efforts. In June, influenza vaccine
manufacturers told federal public health officials to expect
delays in flu vaccine shipments this flu season and possible
shortages. This delay was due to a combination of factors
including problems growing one of the virus strains used in
vaccine and problems in the manufacturing process. Although all
influenza vaccine is produced in the private-sector, and more
than 90 percent distributed through the private-sector, CDC
undertook a number of actions to minimize the adverse impact of
delays. First, CDC contracted for up to 9 million doses of
vaccine to be produced. This added production of additional
influenza vaccine was done to make up for possible shortfalls
experienced by some of the vaccine manufacturer and to help
fill some gaps to vaccinate people at highest risk of
complications of influenza. As a result, flu vaccine supplies
were approximately what was distributed last year; however, a
substantial amount of vaccine reached providers later than
usual. Other actions taken to alleviate problems related to the
delay in influenza vaccine availability included CDC's
initiation of a media campaign to educate providers and the
public regarding the recommendations for this year's influenza
season, development of a web-based system to facilitate the
exchange and redistribution of vaccine and ongoing
communications with health care providers and partners to keep
them informed of influenza vaccine availability.
National Center for Infectious Diseases
Infectious diseases remain a serious problem in the U.S.
Pneumonia and influenza remain the sixth leading cause of death
in the United States and septicemia has risen dramatically
during the past three decades to become the 11th leading cause
of death. Chronic liver disease, a substantial proportion of
which is due to hepatitis C virus, is the 10th leading cause of
death in the U.S. Pneumonia and septicemia are also
contributing and precipitating factors in the deaths of many
Americans with other illnesses, especially cardiovascular
diseases, cancer, and diabetes. Infectious diseases have a
disproportionate impact on older Americans, 65 years old and
older. Quality of life also declines for millions of older
Americans as a result of infectious illnesses. Prevention and
control of infectious diseases will enhance and lengthen the
lives of older Americans, make them more productive, and reduce
associated medical costs.
CDC emphasizes surveillance and training to prevent and
control hospital-acquired and other institutionally acquired
infections in elderly patients. Additionally, CDC staff
provides education regarding infection control to care
providers at nursing home and patient care conferences. This
education focuses on patient care treatment and procedures
associated with the highest risk of infection. Through the
National Nosocomial Infections Surveillance (NNIS) system,
special infection risks of elderly patients have been
identified. According to NNIS, over half of the hospital-
acquired infections occur in elderly patients, although these
patients represent about one-third of all discharges from
hospitals. The use of certain devices, such as urinary
catheters, central lines, and ventilators, are associated with
high risk of infection in all types of patients. In elderly
patients, the risk of infection is high even when a device is
not used, suggesting that infection control must address other
risk factors such as lack of mobility and poor nutrition, in
addition to device use.
Monitoring Influenza
Although delivering the influenza vaccine to persons at
risk is a critical step in preventing illness and death from
influenza, immunization is only part of the prevention
equation. Other CDC efforts to combat influenza in the elderly
include: (1) improving domestic surveillance through the
sentinel and state health department laboratory surveillance
networks; (2) conducting studies to better define the
immunological response of the elderly to influenza vaccines and
to natural infection; (3) conducting immunological studies
involving laboratory and clinical evaluation of inactivated and
live attenuated influenza vaccines in an effort to identify
improved vaccine candidates; (4) increasing surveillance of
influenza in the People's Republic of China and other countries
in the Pacific Basin to better monitor antigenic changes in the
virus; (5) improving methodologies for rapid viral diagnosis;
(6) using recombinant DNA techniques to develop influenza
vaccines that may protect against a wider spectrum of antigenic
variants; and (7) providing laboratory training in the People's
Republic of China, other Pacific Basin countries, and Latin
America to develop and expand capacity for the diagnosis and
detection of antigenic changes in the virus.
Preventing Pneumococcal Disease
Pneumococcal pneumonia causes an estimated 7,500-12,500
deaths each year; about 60 percent of these are in persons 65
years old and older. Prevention of pneumococcal disease in the
elderly requires widespread application of effective
immunization. CDC is currently evaluating the emergence of
drug-resistant pneumococcal strains through laboratory-based
surveillance and is actively promoting increased vaccine use in
the elderly and other groups at risk. New vaccines under
development , including conjugate and common protein antigen
approaches, offer the potential for improved prevention of
pneumococcal disease in the elderly. Improved use of current
vaccine, as well as evaluation of new tools, are critical to
decrease illness and death from pneumococcal infections in the
elderly.
Other Respiratory Infections
Recent studies have suggested that noninfluenza viruses
such as respiratory syncytial virus and the parainfluenza
viruses may be responsible for as much as 15 percent of serious
lower respiratory tract infections in the elderly. These
infections can cause outbreaks that may be controlled by
infection control measures and treated with antiviral drugs. It
is important to define the role of these viruses and risk
factors for these infections among the elderly. CDC is working
to define the disease burden associated with respiratory
syncytial virus and parainfluenza virus infections in the
elderly and helping to develop vaccination strategies for
respiratory syncytial virus.
Healthcare-acquired Infections and Adverse Health Events
The Institute of Medicine (IOM) has reported that
preventable adverse events associated with healthcare result in
98,000 deaths and $29 billion in additional healthcare costs
annually. Overall, 3-4 percent of all patients suffered a
healthcare related adverse event. The elderly are
disproportionately affected by such adverse events.
Existing technology and knowledge can prevent many adverse
events but prevention strategies have not been widely and
successfully implemented. However, some successes have
occurred. For example in 2000, CDC reported that bloodstream
infections among patients in U.S. intensive care units, most of
whom are elderly, declined by 32 percent to 43 percent during
the 1990's (MMWR 2000:49;149-153). This success is due to
improved efforts in infection control in U.S. hospitals, to
technological advances, and to improved patient care. CDC is
embarking on a 5 year plan to substantially reduce bloodstream
infections in other healthcare settings such as cancer and
dialysis centers, respiratory infections in long term care
patients, infections following surgery, and infections due to
antimicrobial resistant organisms. CDC has increased its focus
on the use of new information technologies to improve
efficiency, developed new collaborations with both private
sector partners and public sector partners, and expanded its
work in non-hospital settings (long-term care, home health
care, cancer centers, dialysis centers) where a substantial
portion of healthcare for the elderly is provided. Regarding
antimicrobial resistance, CDC, through the Chicago
Antimicrobial Resistance Project (CARP) is currently evaluating
the impact of infection control strategies on the prevention of
antimicrobial resistance in hospitals and long-term care
facilities.
Group B Streptococcus Disease
Group B streptococcus (GBS) is a major cause of invasive
bacterial disease in elderly persons in the U.S. To document
the magnitude of GBS disease in the elderly and develop
preventive measures, CDC established population-based
surveillance for GBS disease and case control studies to
identify risk factors. An analysis of active surveillance data
from 1993-1998 that was published in the New England Journal of
Medicine in 2000 showed that the incidence of disease in adults
65 years old in 1998 was 20.1/100,000 population
and the case fatality ratio was 15 percent compared to 8
percent in adults 15-64 years old. Consistent with findings
from earlier surveillance, the incidence of disease in black
adults was approximately twice that in non-black adults. These
data, along with serotype data on adult invasive GBS isolates,
will be utilized to develop and evaluate vaccines and to
promote the prevention and treatment of GBS disease in the
elderly population.
Foodborne disease
Foodborne disease is of particular concern in the elderly,
who typically can have higher illness and death rates from
foodborne pathogens than younger persons. Of particular concern
are Salmonella enteritidis infections, often caused by
undercooked eggs, and Escherichia coli O157:H7 infections,
often caused by undercooked hamburger. CDC is working with USDA
and FDA to encourage use of pasteurized eggs in nursing homes
and thorough cooking of hamburger meat.
Listeriosis is a severe bacterial foodborne infection that
particularly affects the elderly, as well as pregnant women and
immunocompromised person. CDC is participating in the
interagency federal control plan for listeriosis, that includes
enhanced surveillance, investigation of sporadic cases and of
outbreaks to determine the sources, so that control measures
can be targeted, and increased efforts to educate persons at
higher risk in prevention measures.
Preventing Legionnaires' Disease
An estimated 8,000-18,000 cases of Legionnaires' disease
occur each year in the United States. Legionnaires' disease is
a severe form of pneumonia caused by the bacterium, Legionella
spp. Between 5-30 percent of persons contracting Legionnaires'
disease die depending on underlying risk factors. The elderly,
particularly those with underlying chronic diseases, are at
greatest risk. Although attack rates are low, legionnaires'
disease can be transmitted when susceptible persons are exposed
to mists that come from a water source (e.g., air conditioning
cooling towers, whirlpool spas, showers) contaminated with
Legionella bacteria. Novel prevention strategies are focusing
on the use of new disinfectants in water systems that may have
the potential for greatly reducing the occurrence of
legionnaires' disease. In addition, CDC is developing improved
surveillance systems to better.
Gastrointestinal Disease
Studies using information from national data bases show
that of all age groups, the elderly (70 years old)
have the highest rates of hospitalizations and deaths
associated with diarrhea in the United States. In the elderly,
caliciviruses (also called Norwalk-like viruses or Small Round
Structured Viruses) are likely to be the most common cause of
both epidemics and sporadic hospitalizations for acute
gastroenteritis and studies needed to confirm this hypothesis
are now underway. These studies should lead to a better
understanding of ways to prevent gastrointestinal disease in
the elderly. The recent identification of rotavirus as a cause
of epidemic diarrhea in the elderly suggests that one approach
to control may involve use of vaccines currently used for young
children. Further study is now needed to determine the
importance of rotavirus to gastrointestinal disease in the
elderly.
Other Infectious Diseases
It is becoming increasingly evident that infections play a
major role in causing or contributing to some chronic diseases.
Some of these conditions result from infection acquired at a
younger age (including liver cancer and cirrhosis related to
chronic hepatitis B or hepatitis C, stomach and duodenal ulcers
or gastric cancer from Helicobacter pylori), while others
develop from exposures later in life. CDC is actively promoting
and pursuing ways to prevent initial infection and the chronic
consequences of such infections. Microbes are also suspected
but not yet proven as triggers of still other chronic
conditions. CDC is developing research activities that identify
and define these relationships. The potential to use infection
control in the prevention or treatment of infections that
produce chronic disease can improve the quality and length of
life for many elderly persons.
National Center for Injury Prevention and Control
CDC's National Center for Injury Prevention (NCIPC) is
involved in a wide array of activities to promote enhanced
mobility and independent living among older Americans by
preventing injuries and injury-related disabilities. Our
research and programmatic efforts that target older Americans
focus on falls prevention, understanding issues affecting older
drivers, and preventing elder abuse. We also support two
organizations focusing broadly on unintentional injury
prevention among older Americans:
The National Resource Center on Aging and
Injury was established at the end of FY1999 with the
San Diego State University. The Resource Center applies
cutting edge technology to collecting, organizing,
evaluating, and disseminating information about
preventing unintentional injuries among older adults.
In FY2000 the Resource Center established a repository
of over 1,000 resource items; developed an interactive
web site (www.olderadultinjury.org) with a searchable
data base; and provided information to over 636,000
people, including health care professionals, care
givers, and other individuals concerned about reducing
injuries among older adults.
The Edward R. Roybal Institute for Applied
Gerontology in Los Angeles, CA is funded to develop
training materials for community organizations and
agencies that serve Hispanic and other minority older
adults in East Los Angeles. These materials enable
organizations to conduct outreach and educational
programs, and to integrate unintentional injury
prevention activities into their existing service
delivery programs.
Falls Prevention
National studies show that one-third of the people over 65
living at home will fall each year, and for people over 80,
this rate increases to 40 percent. Falls are the second leading
cause of injury deaths among persons aged 65 84 years and the
leading cause among persons aged 85 years and older. Of all
fall injuries, hip fractures produce the greatest morbidity and
mortality. Approximately 250,000 hip fractures occur each year
and half of those who sustain hip fractures never regain their
former level of functioning.
Falls are the leading cause of traumatic brain injury (TBI)
among older people, accounting for more than half of TBIs among
older men and more than three-fourths among older women. TBI is
an important and under-recognized public health problem among
older people. NCIPC analyzed population-based data for 1997
from Arkansas, Colorado, and South Carolina (NCIPC-funded
states conducting TBI surveillance), and found that among
people 65 years of age or older who experience TBI, an
estimated 1 in 3 men and 1 in 10 women have a fatal outcome.
Disseminating What Works
A Tool Kit to Prevent Senior Falls, developed in 1999 by
NCIPC, is a comprehensive collection of health education
materials and assessment tools designed to reduce falls and
related injuries among older adults. In FY2000 the Tool Kit was
distributed to over 14,500 organizations and agencies concerned
with preventing injuries among older adults. Pfizer
Pharmaceuticals is mass producing these materials for
distribution to their customers.
NCIPC developed U.S. Fall Prevention Programs for Seniors:
Selected Programs Using Home Assessment and Modification in
November 2000. This document fully describes 18 comprehensive
fall prevention programs as well as contact information for 21
additional programs. These programs are intended to be used as
models by agencies or organizations that want to develop fall
prevention programs for older adults.
Fall Prevention Programs
In September 2000, NCIPC funded the State of California to
conduct a fall prevention demonstration program for community-
dwelling older adults that includes three strategies: increased
physical activity, medication review, and home assessment and
safety modifications. This is the first demonstration of a
combined program of several proven prevention strategies.
NCIPC funded fire/fall prevention programs in September
2000 that target older adults in North Carolina, Minnesota,
Maryland, Virginia and Arizona. These programs implement a pre-
developed program curricula for preventing fire and fall-
related injuries among older adults utilizing home visits,
group presentations, and other innovative outreach strategies.
Gathering Better Data on Falls
In order to understand more about fall risk factors and how
falls occur locations, circumstances, predisposing and enabling
factors, especially for sub-population groups (such as the
oldest old, minorities), NCIPC is supporting the expansion of
the National Electronic Injury Surveillance System of the
Consumer Product Safety Commission to collect information about
fall injuries from hospital emergency departments. We are also
funding the 2nd Injury Control And Risk Survey, a national
injury survey that will include information related to fall
risk factor prevalence and fall prevention behaviors among
seniors.
Research on Falls Prevention
NCIPC conducts research by NCIPC scientists, and through a
peer-reviewed, investigator-initiated grants program in
universities and other research institutions across the
country.
In an NCIPC study using National Hospital Discharge Survey
data, we analyzed hip fracture hospitalization rates occurring
between 1988 and 1996, and found that hip fracture
hospitalization rates for older women increased 40 percent
while the rates for men remained stable. Over 95 percent of hip
fractures were caused by falls.
Previous extramural research on reduction of falls in
nursing homes has shown promising results in reducing falls by
as much as 19 percent. Research has also identified the
following modifiable risk factors: inactivity and muscle
weakness, over medication, and environmental hazards. Less well
understood are other risks, e.g., impaired vision and types of
footwear. To improve our knowledge in one of these areas, NCIPC
is consulting with the Atlanta, GA Veteran's Administration
hospital to study footwear and falls. Current extramural
research grants relating to falls prevention include:
Project Title: ``Hip Fracture Prevention from Falls in the
Elderly''
Project Director: Wilson Hayes, Ph.D.
Institution: Beth Israel Hospital; Orthopedic Biomechanics
Laboratory; Boston, MA
The goals of this project are to understand the
biomechanics of hip fractures among the elderly, to resolve
uncertainties regarding the relative importance of trauma
severity and age-related bone loss, and to design a protective
pad to be worn over the hips and test its acceptability to
potential users.
Project Title: ``An Assessment of Fall Prevention/Safety
Practices in Tennessee Nursing Homes''
Project Director: Wayne Ray, Ph.D.
Institution: Vanderbilt University School of Medicine;
Nashville, Tennessee
This study tests the hypothesis that the Tennessee Fall
Prevention Program (TFPP), a reduces falls that result in
serious injuries. TFPP is a statewide, safety practices
training program for nursing home staff. Investigators are
conducting a randomized controlled trial of an estimated 112
nursing homes with a combined population of approximately 9,000
residents. The primary analysis is assessing program
effectiveness by comparing rates of falls resulting in serious
injuries in intervention and control facilities. If effective,
the TFPP could provide a model for feasible, cost-effective
injury prevention programs in long-term care settings.
Project Title: ``Antidepressants and the Risk of Falls''
Project Director: Wayne Ray, Ph.D.
Institution: Vanderbilt University School of Medicine;
Department of Preventive Medicine; Nashville, Tennessee
The investigator is conducting a retrospective, inception
cohort study of an estimated 2,500 new antidepressant users and
2,500 nonusers for the period of 7/1/93 through 6/30/95. The
study is being conducted in nursing homes because residents
have the highest prevalence of depression and antidepressant
use, are particularly vulnerable to tricyclic antidepressants
adverse effects, and have the highest rates of falls and
related injuries. Study findings are expected to further injury
control by providing information clinicians need to choose
pharmacotherapy that minimizes risk of falls.
Project Title: ``Biomechanics of Injury Prevention During
Falls''
Project Director: Stephen Robinovitch, Ph.D.
Institution: Simon Fraser University; Office of Research
Services; Burnaby, Brit. Col. Canada
Considerable evidence now exists that fall severity, as
defined by the configuration and velocity of the body at
impact, is a stronger predictor than bone density of hip
fracture risk. Data also suggest that specific protective
responses exist for reducing fall severity and fracture risk,
including braking the fall with the outstretched hands, and
absorbing energy in the lower extremity muscles during descent.
This study is designed to better define the biomechanical and
neuromuscular variables that govern safe landing during a fall,
and to identify the neuromuscular variables governing the
efficacy of the protective responses as the basis exists for
designing exercise-based interventions for reducing hip
fractures in the elderly and other fall-related injuries.
Project Title: ``Hip Fracture Reduction with the Penn State
Safety Floor''
Project Director: Donald Streit, Ph.D.
Institution: Pennsylvania State University; Center for
Locomotion Studies; Pennsylvania
This proposal builds upon previous work in which a dually
stiff floor intended to reduce the incidence of hip fractures
in the elderly was successfully designed and developed. The
Penn State Safety Floor (PSUSF) is stiff to loads typical of
everyday activities but yields when forces such as those
encountered during falls occur. Laboratory testing and finite
element modeling have shown the floor to be capable of reducing
the impact force of a fall by 28 percent investigators are now
validating these promising initial results by conducting a
carefully controlled study designed to directly demonstrate
that hip fractures can be reduced by the use of the floor. In
addition, investigators are monitoring a double occupancy room
in a local nursing home where the floor is installed to
demonstrate the livability of the floor.
Older Drivers
In 1999, 7,088 people 65 years and older died in motor
vehicle crashes. People 65 years and older represented 13
percent of the population in 1999 and 17 percent of motor
vehicle deaths. By 2030, elderly people are expected to
represent 20 percent of the population. Once they're in
crashes, elderly people are more susceptible than younger
people to medical complications following motor vehicle
injuries. Little is known about how the physical changes that
accompany the aging process and diagnosed medical conditions
effect driving performance. For example, there is some evidence
to suggest that Parkinson's disease may impair driving,
although the evidence is weak. More needs to be known about the
connection between specific medical conditions and adverse
driving outcomes.
NCIPC has analyzed fatal and nonfatal injury data to assess
trends over time in motor vehicle-related deaths to older
persons. The rate of both fatal and nonfatal motor vehicle-
related injury increased during the study period. Rates
increased as age increased, and men had rates twice as high as
women. NCIPC collaborated with the University of California,
San Diego to explore why older drivers stop driving. This study
found that medical conditions were the most commonly given
reason for stopping, and vision loss was the most common
problem.
NCIPC is also conducting research through peer-reviewed,
investigator-initiated grants program in universities and
research institutions across the country. Research grants
relating to older drivers include:
Project Title: ``Time Since License Renewal and Motor
Vehicle Crash Risk Among Older Drivers''
Project Director: Thomas D. Koepsell, M.D, M.P.H.
Institution: University of Washington, Department of
Epidemiology
States vary considerably with regard to how long a driver's
license remains valid before it must be renewed. Although some
states shorten the time between renewals for older drivers,
most do not. The time between license renewal for older drivers
is a public policy choice, balancing the risk of crashes due to
drivers who have become impaired against the cost and
inconvenience of more frequent renewal checks. The aim of this
project is to determine the relationship between crash risk and
time since last license renewal for drivers 65 years and older.
Investigators hypothesize that longer time periods since last
renewal will be significantly associated with a higher crash
risk, compared to drivers with more recent renewals. The long
term objective is to guide public policy related to license
renewal for older drivers in the United States, by determining
the degree to which decreasing the interval between renewals
for older drivers may lessen the risk of crash.
Project Title: ``Elderly Driver Referral Project''
Project Director: James McKnight, Ph.D.
Institition: National Public Services Research Institute;
Landover, MD
The proposed study attempts to ascertain relationships
between the capabilities of drivers and their safety of
operation in order to enable license administrators to initiate
licensing actions that minimize the threat from those who
cannot operate safely while preserving the mobility of those
who can. The psychophysical capabilities of the entire sample
are being assessed through a battery of test measures designed
specifically to tap capabilities shown to relate separately to
age and highway accidents. The relationships obtained in this
manner are applied to (1) improve the methods of detecting
drivers whose abilities may be diminished by age, (2) develop
tests to validly assess drivers' ability to drive safely, and
(3) formulate licensing actions capable of achieving an optimum
balance between safety and mobility.
Project Title: ``Longitudinal Study of Elderly Drivers''
Project Director/Lead Investigator: Jane Stutts, PhD;
Other Investigators: Richard Stewart, PhD; Carol Hogue,
PhD.
Institution: University of North Carolina at Chapel Hill,
Highway Safety Research Center
A prospective cohort study is underway to assess the impact
of selected functional impairments and medical conditions on
the safety of older drivers. Drivers ages 65 and above coming
in to renew their licenses were asked to participate in the
study which involved a series of visual and cognitive
functional assessments, along with a survey to gather
information on self-reported medical conditions, use of
medications, and driving habits. During the 1\1/2\ year data
collection period, a total of 5,438 license renewal applicants
were identified by the license examiners as potential study
participants. Of these, 3,238, or 60 percent, elected to
participate in the study. Participant and non-participant cases
were linked with the North Carolina driver history files, and
initial data analyses were carried out examining the role of
various cognitive and visual functional impairments in recent
prior crash involvement and in current driving exposure. Follow
up analyses are planned in the project's final year to examine
the usefulness of the driver functional assessments in
predicting future crash involvement.
In addition to these efforts, supplemental funding was made
available by NCIPC to link North Carolina driver history data
to data collected by UNC's Sheps Center for Health Services
Research as part of an earlier study examining changes in
health status and costs associated with Medicare-reimbursed
screening and health promotion services. This ``add-on'' effort
permitted further analyses of associations between motor
vehicle crashes and injuries and a broad range of health
measures in a separate population of elderly NC residents.
Elder Abuse
Abuse of elderly persons is on the rise in the U.S. In
1996, the National Elder Abuse Incidence Study reported 550,000
incidents of abuse among elderly persons. There are no federal
requirements for elderly protective services, nor are there
regulations on training staff who provide protective services
or for those investigating alleged cases of elder abuse. State
protective services for the elderly vary widely; some are
merged with children's services while others are separate.
CDC's NCIPC and Public Health Practice Program Office have
awarded a grant to the University of Iowa to evaluate the
implementation and impact of state adult protective service
statutes and regulations on the conduct of elder abuse
investigations and outcomes. This study is expected to increase
CDC's knowledge and understanding of state regulations related
to elder abuse. Research findings from this study also will aid
in the standardization of definitions in legislation and
healthcare, and inform public health law practitioners about
elder abuse reporting at the state level.
U.S. FOOD AND DRUG ADMINISTRATION
Introduction
According to the U.S. Census Bureau, America's population
aged 65 or older grew by 74 percent between 1970 and 1999, from
20 million to almost 35 million people. As the percentage of
older Americans in the Nation's population continues to
increase the Food and Drug Administration (FDA) has been giving
increasing attention to the elderly in the programs developed
and implemented by the Agency.
Some of the challenges associated with older Americans,
such as multiple drug interactions, food safety, different
physiological characterizations and reactions to drug regimens,
and the need for better medical device design for home self-
diagnostics and therapies, will become more acute. These
challenges will require greater inclusion of the elderly in
clinical testing for drugs, medical devices, and other FDA-
regulated products. Further, the increasing educational needs
of the elderly will require more focused educational programs,
including specific dietary information and foods targeted to
their nutritional requirements. The elderly population and food
service workers who prepare food for the elderly also will
require special education initiatives concerning proper food
handling because as the population ages it becomes more
susceptible to foodborne diseases. Some of the major
initiatives that are underway are described below.
Mission
The FDA is a regulatory consumer protection Agency. FDA's
mission is to promote and protect the public health by
providing timely clearance of safe and effective products and
monitoring products for continued safety after they are in use.
The Agency's primary responsibilities are to ensure that: (1)
foods are safe, nutritious, wholesome, and honestly labeled;
(2) cosmetics are safe and properly labeled; (3) all drug
products used for preventing, diagnosing, and treating disease
are safe and effective, and information on their proper use is
available; (4) biological products (blood and blood products,
test kits, vaccines and antigens, therapeutic agents, and other
biologicals) are safe, potent, and effective for the
prevention, diagnosis, and treatment of disease; (5) medical
devices are safe, effective, and properly labeled, and the
public is not exposed to excessive radiation from medical,
industrial, and consumer products; (6) animal drugs, devices,
and feeds are safe and effective; and (7) food from animals
that are administered drugs are safe for human consumption.
FDA accomplishes its mission through enforcement of the
Federal Food, Drug, and Cosmetic Act and subsequent
regulations. FDA's current areas of emphasis are to implement
the Food and Drug Administration Modernization Act of 1997, to
strengthen the Agency's science-base, and to implement the
Administration's initiatives on food safety and blood safety.
Leveraging Partnerships
Leveraging is the creation of relationships and/or formal
agreements with others outside the FDA that will ultimately
enhance FDA's ability to meet its public health mission. By
choosing to work with other organizations that share our public
health and safety goals, FDA can significantly amplify its
public health impact, leverage the intellectual capital of
others, and make wise use of its resources. FDA has formed many
leveraging partnerships with other government agencies,
regulated industry, academia, health providers, consumers, and
national and community based organizations to help the Agency
meet its public health responsibilities. As part of the
Agency's long-standing tradition of involving the public in its
activities, FDA is forging new relationships with organizations
in the aging network on national and grassroots levels. The
Agency has been quite successful with its collaborations, and
FDA intends to expand and build upon this foundation in
developing new partnerships. During 1999 and 2000, the Agency
conducted a variety of activities intended to establish and
strengthen two-way communication between FDA and its
constituencies. These activities included national and local
consumer roundtables, meetings with organizations, stakeholder
meetings, and public meetings.
Public Participation
FDA has processes that provide access to decision-making
and information programs by its stakeholders. FDA's
stakeholders include industry, small business, consumers, and
health professionals. Stakeholders may interact with FDA policy
makers, express opinions, or ask for information to address
specific concerns. FDA provides balanced opportunities for
public access to the pre- and post-market regulatory processes
in addition to timely education and information.
FDA convened a series of national and local roundtables and
stakeholder meetings with consumers, health professional
associations, and community-based organizations. These forums
provide opportunities for the Agency to dialogue with diverse
groups on the FDA Modernization Act and an array of regulatory
and health policy issues. One of the issues addressed was risk
management associated with the use of medical products, a
significant matter of interest for the older American
community.
Advisory Committee
The Agency continues its efforts to involve older Americans
to serve on its advisory committees by working with aging
organizations to help identify potential candidates. Advisory
committees have served an important role at FDA for many
decades. FDA's advisory committees help the Agency make sound
decisions based on good science in its review of regulated
products. Advisory committees consist of individuals who are
recognized as experts in their field from many different
sectors including medical professionals, scientists and
researchers, industry leaders, consumer representatives, and
patient representatives. While advisory committee
recommendations are valuable, all final decisions related to a
regulated product are made by FDA. Currently there are 32
advisory committees serving the Agency.
Health Fraud
Health fraud is the deceptive promotion and distribution of
false and unproven products and therapies to diagnose, cure,
mitigate, prevent, or treat disease. These fraudulent practices
can be serious and often expensive problems for the elderly. In
addition to economic loss, health fraud can also pose direct
and indirect health hazards to those who are misled by the
promise of quick and easy cures and unrealistic physical
transformations.
The elderly are often the victims of fraudulent schemes.
Almost half of the people over 65 years of age have at least
one chronic condition such as arthritis, hypertension, or a
heart condition. Because of these chronic health problems,
senior citizens provide promoters with a large, vulnerable
market. To combat health fraud, FDA uses a combination of
enforcement and education. In each case, the Agency's decision
on appropriate enforcement action is based on considerations
such as the health hazard potential of the violative product,
the extent of the product's distribution, the nature of any
mislabeling that has occurred, and the jurisdiction of other
agencies.
The FDA has developed a priority system of regulatory
action based on two general categories of health fraud: direct
health hazards and indirect hazards. The Agency regards a
direct health hazard to be extremely serious, and it receives
the Agency's highest priority. FDA takes immediate action to
remove such a product from the market. When the fraud does not
pose a direct health hazard, the FDA may choose from a number
of regulatory options to correct the violation, such as a
warning letter, a seizure, or an injunction.
The Agency also uses education and information to alert the
public to health fraud practices. Both education and
enforcement are enhanced by coalition-building and cooperative
efforts between government and private agencies at the
national, State, and local levels. The Agency also evaluates
its efforts to help ensure that our enforcement and education
initiatives are correctly focused.
The health fraud problem is too big and complex for any one
organization to effectively combat by itself. Therefore, FDA is
working closely with many other groups to build national and
local coalitions against health fraud. By sharing and
coordinating resources, the overall impact of our efforts to
minimize health fraud will be significantly greater. Currently,
FDA is leveraging resources with the Federal Trade Commission
(FTC) in an effort to target Internet health fraud. This
initiative, ``Operation Cure-All,'' is aimed at false and
misleading claims, fraudulent and unproven ``miracle'' cures.
FDA has worked with the National Association of Attorneys
General and other organizations to provide consumers with
information to help avoid health fraud. Since 1986, FDA has
worked with the National Association of Consumer Agency
Administrators (NCAA) to establish the ongoing project called
the NCAA Health Products and Promotions Information Exchange
Network. Information from FDA, the Federal Trade Commission,
the U.S. Postal Service, and State and local offices is
provided to NCAA periodically for inclusion in the Information
Exchange Network. This system provides information on health
products and promotions, consumer education materials for use
in print and broadcast programs, and the names of individuals
in each contributing agency to contact for additional
information.
The Internet poses new and challenging problems to Agency
efforts to prevent health fraud. Snake oil salesmen of the past
have abandoned their wagons to hop on the Internet with offers
of eternal youth and potions for the prevention, treatment and
cure of many diseases. FDA recently seized and destroyed
Chuifong Black Pills, offered as an Asian herbal treatment for
the cure of arthritis. Analysis of the pills showed they
contained several prescription drugs that may pose a serious
health hazard, especially to consumers who were combining
Chuifong with their own prescribed medications.
FDA recently worked with State of California officials to
stop the distribution of an unapproved diabetic drug imported
from China. This herbal product, marketed under several names,
contained the prescription diabetic drug, glyburide. There was
at least one report of an adverse reaction that required
medical treatment. FDA published a brochure in cooperation with
many health care organizations, designed to warn consumers
about buying medical products online. FDA continues to work
with the U.S. Customs Service and state law enforcement
agencies to prevent the Russian product Corvalolum from
entering the United States. Corvalolum contains dangerous
levels of Phenobarbital.
Unapproved new drugs offered as treatments for cancer
continues to be marketed illegally. FDA took action against
Laetrile, a fraudulent cancer cure marketed by two firms. The
Agency obtained a consent decree of permanent injunction
against one firm and the second firm is under a preliminary
injunction as of September 2000.
Another unapproved new drug, hydrazine sulfate, also
marketed illegally as a treatment for cancer, may cause serious
adverse effects. Studies have shown that hydrazine sulfate is
not effective and that it may actually decrease survival time.
The Agency is taking steps to stop the distribution of this
product.
Office of Consumer Affairs
The FDA's Office of Consumer Affairs (OCA) seeks consumer
participation in Agency policy-making and ensures that FDA
decision-makers hear consumer concerns before completing policy
decisions. OCA's primary functions include encouraging public
participation and consumer education and outreach. OCA
routinely includes older Americans in their public
participation, education, and outreach initiatives, as well as
the recruitment process for consumer representatives. OCA
continues to work with its Agency counterparts, as well as its
constituents, to ensure consumer involvement in Agency
processes.
One method the Agency uses to ensure that FDA gets
consumers' points of view is by including consumer
representatives on Agency advisory committees. The role of the
consumer representative is to (1) represent the consumer
perspective on issues and actions before the advisory
committee; (2) serve as a liaison between the committee and
interested consumers, associations, coalitions, and consumer
organizations; and (3) facilitate dialogue with the advisory
committees on scientific issues that affect consumers.
OCA co-sponsored a variety of consumer roundtables and
consumer education programs that highlighted issues of
importance to older Americans. For example:
OCA in conjunction with FDA's Office of
Regulatory Affairs, Pacific Region, convened three
public forums. These forums entitled, ``Public Input on
Public Health, FDA Listens to You, A Town Hall
Meeting'' were held in May 1999 in Oakland, California;
Los Angeles, California; and Portland, Oregon. The
purpose of the forums was to provide an opportunity for
FDA's primary stakeholders, U.S. consumers, to have an
open dialogue with FDA's senior policy makers about
their consumer protection concerns. Some of the topics
addressed were safety and labeling of dietary
supplements, access to clinical trials, health fraud,
and food safety.
On October 26, 1999, ``FDA's Consumer
Roundtable'' was held in Houston, Texas. This meeting
provided an opportunity for consumer to engage in an
open dialogue with senior Agency officials on how FDA
can work with consumers and community organizations to
manage and communicate the risk and benefits of drug
products.
On April 27, 2000, a consumer roundtable
``FDA Celebrates Alliances with Hispanic Communities:
Moving Forward'' was held in San Diego, California.
This roundtable established interaction between the
public and Agency officials on how the Agency can work
with the community to manage and communicate the risks
and benefits associated with drug products.
On December 13, 2000, a discussion was held
in Washington, D.C. between senior FDA officials,
consumer leaders, and consumers to discuss key public
health and consumer protection priorities for the
Agency. The purpose of this roundtable was to
strengthen consumer involvement in the Agency's process
for assessing how it is currently directing its
consumer protection responsibilities and determining
whether there is a need to redirect or shift priorities
to better meet those responsibilities.
Office of Public Affairs
The FDA's Office of Public Affairs (OPA) is the agency's
primary point of contact for the news media. It also manages
the agency's website at www.fda.gov and develops information
materials on FDA-related public health and consumer protection
activities. While working very closely with the different
centers within the agency, OPA has published a number of FDA
Consumer magazines, articles, press releases, and talk papers
that focus on topics of interest and concern to older
Americans.
The agency website has a page dedicated to older Americans
entitled ``FDA Information for Older People.'' This site gives
information regarding buying medicines online, seniors and food
safety, and linkages to other organizations outside of FDA with
information of interest to older Americans. This webpage also
has numerous articles and other publications with information
for older Americans on a wide range of health issues such as:
Arthritis: Timely Treatments for an Ageless
Disease
Help Your Arthritis Treatment Work (Spanish
Version)
Preventing Colon Cancer
FDA Sets Higher Standards for Mammography
Lung Cancer
Prostate Cancer: No One Answer for Testing
or Treatment
Health Claim for Foods That Could Lower
Heart Disease Risk
Keeping Cholesterol Under Control
Taking Charge of Menopause
Taking Time to Use Medicines Wisely
How to Spot Health Fraud
Office of Special Health Issues
The FDA's Office of Special Health Issues (OSHI) serves the
public by answering their questions about the Agency's
activities related to HIV/AIDS, cancer, and other diseases.
OSHI works with patients and their advocates to encourage and
support their active participation in the formulation of FDA
regulatory policy. Additionally, OSHI (1) serves as a channel
through which patient issues and viewpoints can be brought to
the attention of FDA medical and regulatory staff; (2) ensures
a comprehensive and timely response to individuals with
questions and concerns related to life-threatening diseases and
other special health issues; (3) participates in the
development of national policies and practices concerning HIV/
AIDS, cancer, and issues related to special populations; and
(4) provides FDA representation to scientific and policy
meetings related to life-threatening diseases and other special
health concerns.
Office of Women's Health
The FDA's Office of Women's Health (OWH) serves as a
champion for women's health both within and outside the Agency.
To meet its goals OWH (1) ensures that FDA's regulatory and
oversight functions remain gender sensitive and responsive; (2)
works to correct any identified gender disparities in drug,
device, and biologics testing and regulation policy; (3)
monitors the progress of priority women's health initiatives
within FDA; (4) promotes an integrative and interactive
approach regarding women's health issues across all the
organizational components of the FDA; and (5) forms
partnerships with government and non-government entities,
including consumer groups, health advocates, professional
organizations, and industry, to promote FDA's women's health
objectives.
OWH has developed a number of initiatives to further its
inclusion of older Americans in their programs such as:
Take Time To Care (TTTC) encouraged women
nationwide to educate themselves and their families
about using medicines wisely. Educational grassroots
programs were developed with 80 national organizations
and cosponsored by the National Association of Chain
Drugstores (20,000 community pharmacies). Their efforts
coupled with nearly 100 media outlets brought the FDA
message to 26 million readers and viewers. For these
efforts, the Health Care Quality Alliance (97 health
care associations) selected TTTC as a recipient of the
prestigious Pinnacle Award, which annually ``recognizes
pioneering contributions and exemplary leadership in
medication use quality improvement.''
Breast Cancer Awareness Month--In
collaboration with the Center for Devices and
Radiological Health the FDA/OWH sent a letter to all
10,000 certified mammography facilities inviting them
to showcase the availability of our Mammography Today
brochure and distribute a one-page abbreviated version
of the brochure to inform patients about their new
rights.
Pink Ribbon Sunday--OWH sponsored activities
of the FDA Public Affairs Specialists in Houston,
Dallas, and Atlanta to conduct ``Pink Ribbon Sunday''
activities that encourage ``women of color'' to get
screened. In the city of Houston alone, 153 churches
participated and reached about 110,000 people with FDA
materials. The Public Affairs Specialists received the
American Cancer Society's ``Partner of Courage Award.''
Breast Cancer Videotape--OWH developed a
Breast Cancer ``Early Detection Saves Lives'' videotape
to encourage churches to sponsor screening and
educational activities. The videotape will be given to
the Public Affairs Specialists, and the National Cancer
Institute for distribution through their clearinghouse.
New Publications--(1) Created a quarterly
newsletter for our stakeholders focusing on FDA
actions, meetings and activities of interest to women.
(2) Published the first FDA history document describing
the agency's role in protecting women's and the
public's health over the last 100 years. The milestones
presented highlight specific actions taken by the
agency so that all Americans can enjoy safer, healthier
lives.
OWH Website--Redesigned the OWH website that
became a recipient of the ``Hot Site Award.''
Other Outreach Projects (for delivery in FY2001)
OWH will work in partnership with the
American Pharmaceutical Association Foundation and the
National Wholesale Druggists' Association Healthcare
Foundation to promote distribution of TTTC medicine
tips in hospitals. Hospital-based pharmacies will
encourage consumers to play a role in managing risks
associated with medication use as in-patients and out-
patients.
In December 2000, the Emergency Nurses
Association (ENA) announced to its 25,000 members its
decision to adopt TTTC as a national campaign. ENA will
distribute ``My Medicines'' brochures in emergency
settings, hospital auxiliaries, civic meetings, and
retirement homes.
OWH funded a grant for the translation of
materials about cervical and breast cancer screening
for Asian-American Pacific-Islander communities through
a website coordinated by APANet.
OWH funded a bi-regional women's health
conference in DHHS Regions II and III for health
professionals and consumers to raise awareness about
health disparities found in minority communities.
OWH funded the development of a multi-media
Women's Health Care Trainer's Kit and Consumer Guide to
assist women in planning for screenings and preventing
illnesses.
OWH funded a ``Read the Label'' project that
will use graphics to provide instructions for non-
English readers in a variety of Asian languages. This
model may then be applied to other language groups.
Office of Orphan Products Development
It is the intent of the Orphan Drug Act, and the Office of
Orphan Products Development (OPD), to stimulate the development
and approval of products to treat rare diseases. The OPD plays
an active role in helping sponsors meet Agency requirements for
product approval. From 1983--when the Orphan Drug Act was
passed--through the end of 2000, 216 products to treat small
populations of patients were approved by FDA.
By the end of 2000 there were 856 designated orphan
products. One hundred thirty-two of these designated orphan
products (15 percent) represent therapies for diseases
predominately affecting older Americans. Seventy-five are for
treating rare cancers in the elderly, such as ovarian cancer,
pancreatic cancer, and metastatic melanoma. Twenty-two of the
orphan products designated for treating elderly populations
are for rare neurological diseases, such as amyotrophic
lateral sclerosis (ALS), and advanced Parkinson's disease.
Twenty-nine orphan-designated therapies for elderly populations
have received FDA market approval. Most noteworthy among these
is Eldepryl for treatment of idiopathic Parkinson's disease,
postencephalitic Parkinsonism, and symptomatic Parkinsonism;
riluzole for treatment of ALS; and Novantrone for treatment of
refractory prostate cancer.
FDA's orphan product grants had their beginning in 1983 as
one of the incentives provided by the Orphan Drug Act. This
program provides financial support for clinical studies
(clinical trials) to determine the safety and efficacy of
products to treat rare disorders, and to achieve marketing
approval from the FDA under the Federal Food, Drug, and
Cosmetic Act. Studies funded by the orphan products grant
program have contributed to the marketing approval of twenty-
eight products.
Because the orphan products program is issue-specific/
indication-specific, it is typical for an approved product to
be funded under the orphan products grant program for study in
an indication unique to a distinct group of people, such as
women, children, or the elderly. Under the orphan drug program,
disease populations are small and in many instances the firms
themselves are very small. The goal of the Orphan Drug Act is
to bring to market products for rare diseases or conditions. In
so doing, orphan product development promotes research and
labeling of drugs for use by and for special populations. The
orphan products grant program has funded more than 42 studies
aimed at treatment of diseases affecting adults and older
adults.
The National Center for Toxicological Research
The National Center for Toxicological Research's (NCTR)
mission is to conduct peer-reviewed scientific research that
supports and anticipates the FDA's current and future
regulatory needs. This involves fundamental and applied
research specifically designed to define biological mechanisms
of action underlying the toxicity of products regulated by the
FDA. This research is aimed at understanding critical
biological events in the expression of toxicity and at
developing methods to improve assessment of human exposure,
susceptibility, and risk.
NCTR has worked with the National Institute on Aging (NIA)
in the past to study the role caloric restriction plays in the
aging process and what affect a reduced caloric diet has on
disease etiology. The Interagency Agreement with the NIA
terminated in 1999 with the animals that were raised in support
of this work being transferred to Harlan Sprague Dawley, a
commercial laboratory animal breeder. Scientists working on the
Project on Caloric Restriction have concentrated on determining
the mechanisms by which caloric restriction inhibits
spontaneous disease, modulates agent toxicity and affects the
normal aging process. Since 1999 the only studies that have
been continuing are a collaborative study with the University
of Tennessee at Memphis designed to determine if the
physiological, metabolic, and molecular changes that occur with
caloric restriction in rodents are similar in humans, and
additional rodent studies to measure how different levels of
caloric restriction might influence body changes.
Although the work over the last several years has
concentrated on the mechanisms of toxic interaction in the body
and the role caloric restriction has on this process, studies
with calorically restricted animals have repeatedly shown that
caloric restriction extends the life span of animals. How this
affects aging is still in question; however, the research being
conducted in this area is continuing to chip away at the
problem of how diet affects the aging process, and what
elements or lack thereof in the human diet may help to extend
human life.
Medwatch
MedWatch, the FDA's voluntary Medical Products Reporting
and Safety Information Program, serves both healthcare
professionals and the medical product-using public. MedWatch
strives to educate health professionals about the critical
importance of being aware of, monitoring for, and reporting
adverse events and product problems to FDA and/or the
manufacturer, as well as to ensure that new safety information
is rapidly communicated to the medical community, thereby
improving patient care. The purpose of the MedWatch program is
to enhance the effectiveness of postmarketing surveillance of
medical products as they are used in clinical practice and to
assist in rapidly disseminating information about significant
health hazards associated with these products. Health
professionals, as well as consumers, are encouraged to report
serious adverse reactions and product problems associated with
FDA-regulated products to the Agency.
Older Americans are generally more susceptible to adverse
events because of the probability they will use more
medications and medical device products.
Center for Devices and Radiological Health
The FDA's Center for Devices and Radiological Health (CDRH)
promotes and protects the health of the public by ensuring the
safety and effectiveness of medical devices and the safety of
radiological products. Medical devices include products ranging
from mechanical heart valves to ophthalmic lasers to pregnancy
test kits products that are intended for use in the diagnosis
of disease or other conditions, or in the cure, mitigation,
treatment or prevention of disease. Radiation-emitting
electronic products include such things as microwave ovens,
televisions, sunlamps, medical and baggage inspection x-ray
machines, and laser products such CD and DVD players, light
shows and bar code scanners. CDRH provides information to
consumers, including older Americans, regarding medical devices
and radiation-emitting products to enhance their ability to
avoid risk, achieve maximum benefit, and make informed
decisions about the use of such products.
Mammography
Because a woman's risk for breast cancer increases as she
gets older, the need to have a regularly scheduled mammogram is
critical to ensure early detection. Congress enacted the
Mammography Quality Standards Act of 1992 (MQSA) to ensure that
all women have access to quality mammography for the detection
of breast cancer in its earliest, most treatable stages.
As of April 28, 2000, there were 9,994 MQSA-certified
mammography facilities in the United States and its
territories. All of these facilities are subject to clinical
accreditation by outside expert bodies, and certification and
inspection by FDA to ensure compliance with quality standards.
Older women are the focus of this effort:
CDRH targets older Americans for particular
outreach efforts. Groups such as AARP have been on our
mailing list to receive mammography information and
Mammography Matters (our newsletter) since the
inception of our program.
CDRH has collaborated extensively with FDA's
Offices for Women's Health, Consumer Affairs, Public
Affairs, and Special Health Issues, and they have
distributed educational materials about mammography to
their constituents, including newsletter editors.
Older Americans were included in the
outreach about the availability of the 1-800-4-Cancer
hotline. Callers to this number can locate FDA-
certified mammography facilities in their areas, get
answers to questions about breast cancer, and request
publications.
Consumer representatives with ties to senior
advocacy groups are members of our National Mammography
Quality Assurance Advisory Committee.
Hospital Bed Safety
FDA continues its work to reduce the hazards associated
with patient entrapment in hospital beds. Patient entrapment
with hospital bedside rails can occur in hospitals, nursing
homes and at home. The FDA continues to receive reports of
death and injury when patients become entangled or trapped
between the mattress and bed rail or in the bed rail openings.
The patients most at risk for entrapment are frail, elderly or
confused.
FDA initiated and is an active member of The Hospital Bed
Safety Work Group, which most recently met in Chicago on
October 24-25, 2000. The Hospital Bed Safety Work Group is made
up of representatives of the federal government, national
health care organizations, manufacturers of hospital beds and
medical researchers. To date, the work group has primarily
focused on raising awareness of the entrapment hazard and
educating caregivers and family members on the problems
associated with bed rail use. The work group recently issued an
educational brochure, ``A Guide to Bed Safety,'' that
highlights the benefits and risks of bed rails, ways to meet a
patient's need for safety, and patient or family concerns about
bed rail use. This brochure and the work of The Hospital Bed
Safety Work Group are available on the FDA web site for bed
safety at: http://www.fda.gov/cdrh/beds/. Planned work includes
developing clinical guidance for caregivers on appropriate bed
rail use and developing a measurement tool for clinical
facilities to determine if an entrapment hazard exists with
their beds.
Treatment for Benign Prostatic Hyperplasia
On October 11, 2000, FDA sent a Public Health Notification
to alert the medical community of the potential for serious
injuries from microwave thermotherapy for benign prostatic
hyperplasia (BPH). Although the use of microwave thermotherapy
for the treatment of BPH has been demonstrated to be safe and
effective, FDA is concerned about reports of unexpected
procedure-related complications that have occurred since the
marketing of these devices. The letter identified several
factors that may have contributed to the injuries and made
recommendations to avoid injury.
Medical Device Approvals
Heart and Cardiovascular System
The AngioJet System, approved on March 15,
1999, removes blood clots from blocked heart arteries
or bypass grafts prior to angioplasty. The device will
provide an alternative treatment to so-called clot-
busting drugs, and will be particularly useful for
patients in whom these drugs cannot be used.
On November 6, 2000, FDA approved the Cordis
CheckmateTM System and the Novoste Beta-
CathTM System, both of which use catheters
to deliver radiation inside a coronary stent, following
the opening of a blocked artery. The radiation helps
reduce the risk of new tissue growth inside the
coronary stent and the resulting narrowing of the
artery.
FDA continues to review and approve for
marketing improved versions of heart valves,
pacemakers, implanted cardioverter defibrillators and
other cardiac devices that will help many older
Americans live longer, more comfortable lives.
Vision
Verteporfin for injection (Visudyne), the
first therapy to slow vision loss in people with
classic ``Wet Age-Related Macular Degeneration (AMD)''
was approved on April 13, 2000. AMD, a retinal disease
causing severe and irreversible vision loss, is a major
cause of blindness in individuals older than 60 years
in the Western World.
Cancer
Approved on April 19, 1999, the T-SCAN 2000
is intended for use as a follow-up step to mammography
for patients whose mammograms are ambiguous. The device
has the potential to reduce the number of negative
biopsies, thus saving women worry about breast lesions
that turn out to be non-cancerous.
Approved January 31, 2000, the Senographe
2000D is the first mammography system that produces
digital images on a solid state receptor instead of
analog images on a radiographic film. Unlike
radiographic film, digital images can be electronically
stored and transferred, so that a specialist at a
remote location can evaluate them. The images also can
be manipulated to correct for under- or over-exposure.
Early diagnosis remains the best weapon against breast
cancer, which annually affects 185,000 women, 46,0000
of whom die of the disease. Most women who get breast
cancer are over 50 years of age. The approval of
digital mammography benefits older Americans because
the ability to manipulate computer images means fewer
call-backs for additional imaging, which can be
difficult for older Americans who often depend on
others for their transportation.
FDA allowed continued marketing of two types
of saline-filled breast implants that had been approved
for breast reconstruction and for breast augmentation
in women 18 years or older. This decision was made
following the conclusion of clinical studies involving
9,000 women and the recommendations of our expert
advisory committee. Many women feel that breast
reconstruction is an essential part of their recovery
after mastectomy because of breast cancer.
The Optical Biopsy System is a laser system
that improves a physician's ability to identify
suspicious growths in the colon. It is operated through
an endoscope and can be used to evaluate polyps less
than 1 cm in diameter. This device was approved on
November 15, 2000.
Another device, FocalSeal-L Surgical
Sealant, was approved on May 30, 2000, for sealing air
leaks in lungs following the removal of cancerous
tumors. FDA reviewed the sealant, which is ``painted''
on the lung and activated by light, on an expedited
basis because of its potential importance for patients
with lung cancer.
Levulan Kerastick (aminolevulinic acid HCI)
for Topical Solution, 20 percent is to be used in
conjunction with photodynamic therapy for treatment of
actinic keratoses (AKs) (pre-cancerous skin lesions) of
the face or scalp. AKs are rough, scaly, red or brown
patches that begin on the surface of the skin. They are
mostly found among individuals with light complexions
affecting more than 50 percent of elderly fair-skinned
persons in hot, sunny climates. This product was
approved on December 6, 1999.
Diabetes
The Continuous Glucose Monitoring System,
approved on June 16, 1999, provides physicians with
continuous measures of tissue glucose levels in adults
with diabetes.
Apligraf is intended to be used on patients
who have not responded well to standard methods of
treating foot ulcers. Approved on June 20, 2000,
Apligraf is a cellular, bi-layered skin substitute
produced from bovine collagen and cells derived from
human infant foreskins. Many diabetics have difficulty
healing and might benefit from this product.
Pneumonia
A laboratory test for detecting
Streptococcus pneumoniae, one of the bacteria that is a
leading cause of pneumonia was approved on August 30,
1999. Pneumonia can be a life-threatening disease for
the elderly.
Hearing Loss
Vibrant Soundbridge is a surgically
implanted hearing device intended to help adults with
moderate to severe nerve hearing loss. Approved on
August 31, 2000, this device is an alternative for
people who have not been helped by hearing aids. About
20 percent of Americans--more than 56 million--
experience some nerve deafness by the age of 55.
Research
Gender effects on coronary arteries and balloon
angioplasty.--FDA scientists have established a large animal
cardiovascular research program to develop and study models of
cardiovascular disease, vascular injury, and long-term vascular
implant performance. FDA scientists are using the laboratory to
study effects of gender and hormonal state on the function and
mechanical properties of coronary arteries and on the response
of arteries to balloon injury. More than 75 subjects have been
studied and the results thus far will be announced at the FDA
Science Forum in February 2001. The motivation for the study is
the observed greater incidence of cardiovascular death in
postmenopausal women and men of all ages compared to
premenopausal women.
Early detection of diabetes-related eye diseases.--One of
the most threatening aspects of diabetes is the development of
visual impairment due to cataract formation, diabetic
retinopathy, and glaucoma. In many cases, diabetes-related
ocular pathologies go undiagnosed until visual function is
compromised. In order to develop techniques for early cataract
detection, FDA scientists are studying the progression of
diabetes in a unique animal model and monitoring the changes in
the lens using a safe, nondestructive dynamic light scattering
technique.
Ultrasonic measurement of bone density.--FDA has approved
several ultrasound bone densitometers, which are used in the
assessment of osteoporosis, and more applications for these
devices are in progress. Because this is a new technology,
there is little standardization between devices, and the
technology is likely to continue evolving. FDA scientists are
investigating the ultrasonic measurements (backscatter,
attenuation, and sound speed) on 50 women ranging in age from
50-90. The objective is to investigate the diagnostic utility
of the backscatter measurement for diagnosis of osteoporosis.
Preliminary experiments conducted on bone samples in vitro
increased understanding of how and why ultrasound bone
sonometry is effective and should, therefore, lead to better
review of these devices.
Acoustic detection of cavitation near heart valves.--
Transient cavitation--the formation and collapse of tiny
bubbles in the blood--has been observed near operating
mechanical heart valves. Cavitation can damage the valve and
break down the blood cells. FDA is conducting studies to
determine if the broad-spectrum acoustic energy that occurs
when the bubbles collapse might be used to detect cavitation by
``listening'' with a hydrophone to the noise produced by valve
closing when cavitation is present.
Electromagnetic interference with electronic implants.--
CDRH scientists have conducted studies to help determine the
risk of various magnetic fields to electronic implanted medical
devices. Magnetic fields from various types of electrical
equipment can interfere with the proper operation of implanted
medical devices, such as cardiac pacemakers and defibrillators,
and spinal cord stimulators. CDRH engineers have completed
magnetic and electric field mapping of eight electronic article
surveillance systems. A special laboratory environment was
required to conduct this study. CDRH's three-dimensional
electromagnetic field-strength mapping apparatus was relocated
to a new laboratory and the required support structure was
designed and constructed using non-magnetic components; a walk-
through metal detector was obtained from the Federal Aviation
Administration. The results of these tests were published in
the September-October 1999 issue of Compliance Engineering.
Standards Development.--CDRH scientists have participated
heavily in the development of performance standards for many
types of devices of interest to older Americans. These include
standards for devices to relieve the consequences of arthritis
such as total orthopedic joints and mobility aids such as
wheelchairs, as well as devices to assist the cardiovascular
system such as pacemakers, heart valves, and cardiovascular
stents. CDRH currently supports more than 500 domestic and
international standards development efforts.
Website
CDRH's website provides consumer information on many topics
of interest to older Americans such as mammography, newly
approved medical devices, and reducing user error. There are
also webpages devoted to LASIK, the popular laser surgery for
improving vision, and the safety of hospital beds. CDRH's
website can be found at http://www.fda.gov/cdrh/index.html.
Publications
``Mammography Today: Questions and Answers
for Patients on Being Informed Consumers--Better
Treatments Save More Lives''
``FDA Sets Higher Standards for
Mammography''
Mammography Matters newsletter
``A Guide to Bed Safety; Bed Rails in
Hospitals, Nursing Homes and Home Health Care: The
Facts''
``Breast Implant Risks''
``Breast Implants An Information Update--
2000''
CDRH FDA & HHS Press Releases, Fact Sheets, Public Health Notifications
and Statements Related to Older Americans
FDA Approves New Device To Remove Blood
Clots From Coronary Arteries (Angio-jet)--March 15,
1999
FDA Approves New Breast Imaging Device (T-
Scan)--April 19. 1999
Potential Cross-Contamination Linked to Hem
odialysis Treatment--May 1999
Laser Facts--June 1999
FDA Clears Quick New Lab Test for Pneumonia
Antigen--August 30, 1999
Consumer Update on Mobile Phones--October
20, 1999
Temporomandibular Joint Implants: A Consumer
Information Update--November 1999
First Drug Device Combined Treatment for
Certain Pre-Cancerous Skin Lesions Approved--December
6, 1999
FDA Statement about ColorMax Eyeglass
Lenses--December 21, 1999
FDA Approves First Digital Mammography
System--January 31, 2000
Risks of Burns from Eruption of Hot Water
Overheated in Microwave Ovens--March 8, 2000
Microwave Oven Radiation--March 8, 2000
FDA Alerts Health Professionals and
Consumers to a Nationwide Recall of Clinipad Antiseptic
Sterile Products--March 10, 2000
FDA Approves Treatment for Wet Macular
Degeneration--April 13, 2000
Two Firms Get FDA Approval To Continue
Marketing Saline-Filled Breast Implants--May 10, 2000
FDA Approves New Surgical Sealant For Lung
Cancer--May 30, 2000
FDA Approves New Product For Diabetic Foot
Ulcers--June 20, 2000
Risk of Electromagnetic Interference with
Medical Telemetry Systems--July 10, 2000
Serious Injuries from Microwave
Thermotherapy for Benign Prostatic Hyperplasia--October
11, 2000
FDA Approves New Implanted Hearing Device--
October 23, 2000
FDA Approves Two New Devices To Help Reduce
the Risk of Repeat Coronary Stent Re--Narrowing (In-
Stent Restenosis)--November 6, 2000
FDA Approves New Device To Help Distinguish
Harmless from Pre-Cancerous Growths in Colon--November
15, 2000
Court Orders Refund to Purchasers of Gas
Grill Igniters Marketed for Pain Relief--November 30,
2000
Center for Drug Evaluation and Research
The mission of FDA's Center for Drug Evaluation and
Research (CDER) is to promote and protect the public health by
helping to ensure that safe and effective drugs are available
to the American public including older Americans. FDA is
continuing to make drugs safer for older Americans, who consume
a large share of the nation's medications. Adults over age 65
buy 30 percent of all prescription drugs and 40 percent of all
over-the-counter (OTC) drugs.
Public Participation
CDER continues to maintain its long-standing tradition of
involving the public in its activities. On June 28 and 29,
2000, FDA held a public meeting to get input and opinions on
the type of drugs for which it would be appropriate to switch
from prescription status to OTC status. Many of the drugs
discussed were drugs commonly used by the aging population in
America. For example, one part of the meeting focused on
cholesterol-lowering drugs and whether they should be
considered as candidates for OTC drug status. The meeting
attracted considerable attention from consumer and patient
groups, as well as industry, and was covered by C-Span.
OTC Labeling Changes Campaign
Many older Americans find the print on OTC labels too small
to be legible. In 1997, FDA issued a proposal to establish a
standardized format for the labeling of OTC drug products and
provided over 7 months for interested persons to comment on the
OTC labeling proposal. The Agency received more than 1,800
comments from health professionals, students, professional
organizations, trade associations, manufacturers, consumers,
and consumer organizations. An overwhelming majority of the
comments supported the Agency's initiative to standardize the
format of OTC drug product labeling and to make the labeling
easier to read and understand by requiring a minimum type size,
user-friendly headings, and other well-accepted visual cues.
The regulations became effective on April 16, 1999. In many
cases, OTC drugs with the new labeling will begin appearing on
the shelves by 2002. The remainder of more than 100,000 OTC
drugs will be required to adopt the new labeling within the
next six years. CDER reached more than 17 million people with a
print campaign and 137 million listeners with radio Public
Service Announcements notifying them of the OTC labeling
changes.
Materials, Outreach, and Exhibits
The FDA continually strives to establish an ongoing
dialogue between the Agency and its constituents on important
public health problems and issues. Of recent interest is the
use of the Internet by the public to buy medical products. Many
consumers, including older Americans or those who cannot leave
their homes, benefit from the convenience and privacy of this
new option. The safe use of the Internet by consumers is
threatened, however, by fraudulent or disreputable Internet
pharmacies that sell products illegally. CDER prepared a
brochure, a newspaper article, and a print Public Service
Announcement designed to inform the public about the potential
dangers of buying medical products on the Internet, and to
increase consumer awareness about the problems related to
online drug purchases. This information is available on FDA's
website on www.fda.gov.
In addition, the Agency actively participated in outreach
activities including a two-day national workshop with the
National Patient Safety Foundation to address the safe use of
medical products from the consumer and patient perspectives.
Held in March 2000, one of the goals of the meeting was to
stimulate a national dialogue about safe medical treatment
among consumer groups and health professional organizations.
Following the meeting, CDER produced four videotaped
presentations to be used during future public meetings about
safe medical treatments. In May 2000, CDER provided an exhibit
at the First National Conference of the American Society of
Aging and the National Council of the American Association of
Retired Persons in Orlando, Florida.
Finally, CDER has prepared several brochures specifically
for older Americans. Titles include: ``AgePage, Medicines: Use
Them Safely,'' ``Reducing Your Risk of Heart Attack or Stroke
with Aspirin Therapy: Know the Facts,'' and ``Be an Active
Member of Your Health Care Team.''
Postmarket Drug Surveillance and Epidemiology
CDER's Office of Postmarketing Drug Risk Assessment is
responsible for receiving, entering into a database, and
analyzing reports sent to the Agency on adverse reactions to
drugs. In 1999, there were approximately 261,000 reports
entered into CDER's Adverse Event Reporting System. For 2000,
the approximate number increased to 300,000. Reports
representing patients aged 65 years or older numbered 54,000
(21 percent of total for 1999) and 52,000 (17 percent of total
for 2000). These percentages are similar to those reported in
the past.
Geriatric Labeling
On December 11, 1998, the Agency made public a draft
publication entitled: ``Guidance for Industry on the Content
and Format for Geriatric Labeling.'' This guidance discusses
the following issues related to the submission of geriatric
labeling: 1) who should submit revised labeling; 2)
implementation dates; 3) description of the regulation and
optional standard language in proposed labeling; 4) content and
format for geriatric labeling; and 5) applicability of user
fees to geriatric labeling supplements. Comments submitted to
the proposed rule currently are being addressed by the Agency.
Generic Drugs
During 1999-2000, FDA's Office of Generic Drugs approved
699 abbreviated new drug applications. These drug products are
often substantially less expensive and provide a safe and
effective alternative to brand-name products. Many of these
approvals represent the first time a generic drug was made
available for products of special interest to older Americans
such as doxazosin mesylate capsules used in the treatment of
enlarged prostate and hypertension, paclitaxel injection used
in the treatment of various ovarian and breast cancers, and
digoxin tablets used in the treatment of heart failure. These
and other recently approved generic drug products could save
the American public and federal government millions of dollars.
In July 1998 the Congressional Budget Office (CBO) published a
report: How Increased Competition from Generic Drugs Has
Affected Prices and Returns in the Pharmaceutical Industry. The
CBO estimated that in 1994, purchasers saved between $8 billion
to $10 billion on prescriptions at retail pharmacies by
substituting generic drugs for their brand-name counterparts.
Center for Food Safety and Applied Nutrition
While the American food supply is among the safest in the
world, there are still too many Americans stricken by illness
every year caused by the food they consume, and some mostly the
very young, elderly, and the immune compromised die every year
as a result. The FDA's Center for Food Safety and Applied
Nutrition (CFSAN) promotes and protects the public health and
economic interest by striving to be a leader in food safety,
protecting consumers from economic fraud, promoting sound
nutrition, and encouraging innovation. The following programs
and activities demonstrate the center's commitment to provide
benefits for older Americans.
CFSAN's Outreach and Information Center
CFSAN's new Outreach and Information Center (O&IC)
considerably expanded access and assistance to all consumers
throughout the country, especially older consumers. Expanding
coverage of the live toll-free Information Line, 1-888-SAFEFOOD
(10:00-4:00) was particularly beneficial since a large
proportion must rely on the telephone for information. Of the
55,000 calls received, a majority were from older persons
seeking information on a variety of food and cosmetic-related
issues. With more now having access to computers, we have seen
a steady increase in the number of older consumers requesting
food safety information through CFSAN's electronic-mail system.
However, we also responded to more that 2500 written letters,
again a majority from older persons. Most notably, older
consumers are the single largest group requesting FDA/CFSAN
publications and other materials. The O&IC and the Consumer
Education Staff have developed workshops, served as presenters,
provided materials and staffed exhibits at conferences
throughout the country, with a particular focus on providing
information to older consumers.
Food Safety Campaign Aimed at Seniors is Launched
``To Your Health! Food Safety for Seniors'' is a new
educational program developed by CFSAN's Food Safety Initiative
staff and the U.S. Department of Agriculture's Food Safety and
Inspection Service. The materials focus on seniors because they
are one of the more susceptible populations for developing
foodborne illness. And once they become sick, they face the
risk of more serious health problems, even death.
The 14-minute video and companion publication were designed
in cooperation with a variety of senior advisors including
representatives from the Administration on Aging, the State
Units on Aging, and the National Institutes of Health. In
format and design, the materials are tailored to seniors. The
publication features large type to make easy reading for older
eyes. The graphics are colorful and bold. The video contains
portraits of other seniors. Through them, we learn about safe
food handling at home and food safety when eating out. This
program is not targeted to seniors who are living in nursing
homes or assisted-living facilities where all meals are
provided.
A comprehensive, nationwide distribution plan is underway
for the 550,000 publications and 47,000 videos produced. Health
educators and program leaders at more than 10,000 senior
centers; 5,000 county extension offices; 5,000 county health
departments 1,000 area offices of aging; 50 state extension and
health departments; as well as 50 national organizations
representing seniors will be receiving the materials. FDA's
Public Affairs Specialists will be complementing this
distribution with their own outreach activities. Individual
consumers can receive a free copy of the publication by
contacting the Consumer Information Center in Pueblo, Colorado.
A small supply of publications and videos are in stock. If you
would like a copy of the publication, please contact
Laura Fox, FSI Education Team, at 202-260-0574; or by e-mail to
[email protected]. The video will shortly be on the CFSAN
Intranet.
Program Priority Accomplishments
The following is a listing of program priority
accomplishments for CFSAN. Each of these accomplishments
addresses an action taken by the Agency to enhance the lives of
consumers while protecting the U.S. food supply and promoting
public health. With an increase in the variety of foods and the
number of convenience items that are currently available to
consumers in the market place a number of public health
concerns have evolved, especially for older Americans because
of their greater susceptibility to illnesses. The
accomplishments listed below will address some of those
concerns.
Nutrition, Health Claims, and Labeling--
CFSAN published a final rule authorizing a health claim
for soy protein and heart disease (21 CFR 101.82) on
October 26, 1999. CFSAN completed the evaluation of two
additional health claim petitions within statutory
timeframes. One petition was for sterol esters and
heart disease. The other was for stanol esters and
heart disease. The agency issued an interim final rule
authorizing these health claims on September 8, 2000
(65 FR 54686)(21 CFR 1010.83).
Food Safety Report--In accordance with
Senate Report 106-80, in consultation with the U.S.
Department of Agriculture, prepared a report to
Congress on how to educate the public about the safety
of our food supply.
Public Meeting--Held a public meeting in
Chicago, Illinois on July 21, 2000 to discuss the use
of term ``fresh'' in the labeling of foods processed
with alternative non-thermal technologies. The purpose
of this meeting was to solicit views on whether the use
of the term ``fresh'' is truthful and non-misleading on
foods processed with these alternative technologies and
on what type of criteria FDA should use when
considering the use of the term with future
technologies.
Enforcement Procedures--CFSAN established
procedures to evaluate food label complaints and
respond to significant or precedent setting
discrepancies in food labeling.
Safety Issues--Contracts were arranged with
the National Academy of Science's Institute of Medicine
to establish a scientific framework for assessing the
safety of dietary supplements, and to apply that
framework to several specific dietary supplement
products.
Ephedra--Published three Federal Register
notices announcing the availability of new adverse
event reports and related information on dietary
supplements containing ephedrine alkaloids, and
announcing withdrawal of the provisions of the
ephedrine alkaloids proposed rule relating to the
dietary ingredient level and duration of use limit for
these products (65 FR 17474-17510; April 3, 2000).
Participated in a public meeting on August 8-9, 2000
sponsored by the Public Health Service, to discuss the
available information about the safety of dietary
supplements containing ephedrine alkaloids.
Health Claim Regarding Fiber and Colorectal
Cancer--On October 10, 2000 issued a final
determination on a second of the four Pearson claims.
FDA determined that the proposed health claim about
dietary fiber and reduced risk of colorectal cancer
could not be authorized because the results of studies
about dietary fiber consistently showed a lack of
relationship between dietary fiber supplements and the
risk of colorectal cancer. Neither could the claim be
qualified because the suitable evidence against the
claim outweighed the evidence for it.
Health Claim Regarding Omega-3 Fatty Acids
and Coronary Heart Disease--On October 31, 2000 issued
a final determination on the third of four Pearson
claims. FDA is using its enforcement discretion to
allow a qualified claim about the use of omega-3 fatty
acids in dietary supplements and the reduced risk of
coronary heart disease. The qualified claim applies to
daily intakes that do not exceed three grams per person
per day from conventional food and dietary supplement
sources.
Claims for Mitigation of Disease--Following
a public meeting on May 26, 2000 denied a petition
requesting authorization of a health claim concerning
the relationship between dietary supplements containing
saw palmetto and benign prostatic hyperplasia (BPH).
FDA's response noted that claims about effects on
existing diseases do not fall within the scope of the
health claim provisions of the Act and therefore may
not be the subject of an authorized health claim.
Health Claim Petitions--CFSAN continues to
meet its statutory obligations for health claims for
dietary supplements. CFSAN denied, by operation of the
statue (on December 1, 1999) and formally on May 26,
2000 a health claim for saw palmetto extracts and
symptoms of BPH. CFSAN also denied on January 11, 2000
a petition for vitamin E and heart disease due to lack
of significant scientific agreement to support the
claim.
Dietary Supplement Strategic Plan--On
January 3, 2000 the Dietary Supplement Strategic Plan
was distributed to stakeholders and posted on the web
page. The plan establishes a clear program goal to
have, by the year 2010, a science-based regulatory
program that fully implements the Dietary Supplement
Health and Education Act of 1994, and that provides
consumers with a high level of confidence in the
safety, composition, and labeling of dietary
supplements products.
Bottled Water Feasibility Study--Solicited
comments on the draft feasibility study in the Federal
register of February 22, 2000 (65 FR 8718) and
published in the Federal register of August 25, 2000
(65 FR 51833), a final report on the feasibility of
appropriate methods of informing customers of the
contents of bottled water, as required by the Safe
Drinking Water Act Amendments.
Advisory Committee--A standing Dietary
Supplement Subcommittee was officially added to the
restructured Food Advisory Committee on June 26, 2000.
A request for membership nominees having the requisite
scientific expertise to serve on the new subcommittee
appeared in the Federal Register on July 28, 2000 (65
FR 46463).
Biotechnology--On May 3, 2000 made a public
announcement on plans to strengthen the regulatory
approach for bioengineered foods. Three initiatives
were announced: (1) Development of a proposed rule
requiring that developers of bioengineered foods notify
the agency before they market such products; (2) the
addition of scientists to the Food Advisory Committee
that have expertise in biotechnology; and (3) the
development of labeling guidance to assist
manufacturers who wish to voluntarily label their foods
being made with or without the use of bioengineered
ingredients.
Food Allergens--Held meetings at 14
locations to raise consumer and industry awareness to
the presence of allergens in foods and on labeling
approaches to identify the presence of allergens.
Food Safety Initiative--Completed
development of the survey instrument for the Food
Safety Consumer Survey Cycle IV. The survey is used to
monitor the impact of food safety initiatives and to
identify consumer education needs.
Dietary Supplements--Communicated dietary
supplement enforcement policies and procedures to the
general public, FDA field offices, health care
professionals, and industry. The Agency met with
several organizations to share information concerning
dietary supplement enforcement policies and procedures.
CFSAN--FDA & HHS Press Releases, Talk
Papers, Fact Sheets and Statements
7/1/99--New Egg Safety Steps Announced,
Safe Handling Labels and Refrigeration will be
Required
7/9/99--Consumers Advised of Risks
Associated with Raw Sprouts
7/10/99--FDA Issues Nationwide Health
Warning about Sun Orchard Unpasteurized Orange
Juice Brand products
10/1/99--FDA Issues Nationwide Public
Health Advisory about Contaminated Pet Chews
10/20/99--FDA Approves New Health Claim for
Soy Protein and Coronary Heart Disease
10/25/99--FDA Issues Guidance to Enhance
Safety of Sprouts
11/16/99--FDA Issues Warning About Sun
Orchard Fresh Squeezed Unpasteurized Orange
Juice
11/19/99--Sun Orchard Adds an Additional
Production Code to its unpasteurized Orange
Juice Recalled Because of Possible Health Risk
12/23/99--Nationwide Recall of Certain
Royal Baltic Brand Smoked Fish Products Due to
Potential Health Risk
1/5/00--FDA Finalizes Rules for Claims on
Dietary Supplements
1/10/00--Royal Baltic expands Nationwide
Recall of Smoked Fish Products Due to Potential
Health Risk
1/27/00--FDA Issues Nationwide Warning on
Felix's, Trader Joe's, Delicioso, and the
Carryout Cafe Brands of 5 Layer Dip because of
Possible Health Risk
2/10/00--FDA Public Health Advisory: Risk
of Drug Interactions with St. John's Wort and
Indinavir and Other Drugs
5/26/00--FDA Advises Consumers About Fresh
Produce Safety
9/5/00--FDA Authorizes New Coronary Heart
Disease Health Claim for Plant Sterol and Plant
Stanol Esters
9/8/00--FDA Database of Foodborne Illness
Risk Factors Released
11/21/00--FDA Warns Against Consuming
Dietary Supplements Containing Tiratricol
11/24/00--FDA Announces Nationwide Recall
of Certain Soups Due to Potential Health Risk
From Botulism
11/30/00--FDA Finalizes Safe Handling
Labels and Refrigeration Requirements for
Marketing Shell Eggs
Website
CFSAN's website has an informational page entitled,
``Seniors and Food Safety.'' This page gives a broad spectrum
of information about foodborne illness, food preparation and
storage and additional links for seniors. Also on CFSAN's
website is another informational page entitled, ``Information
for Women Over 65 Years Old.'' This site has links to
information on food, nutrition, cosmetics, publications for
older consumers, mammography and medications from the agency as
well as links to other federal government agencies.
Center for Veterinary Medicine
The FDA's Center for Veterinary Medicine (CVM) regulates
the manufacture and distribution of food additives and drugs
that will be given to animals. These include animals from which
human foods are derived, as well as food additives and drugs
for pet (or companion) animals. CVM is responsible for
regulating drugs, devices, and food additives given to, or used
on, over one hundred million companion animals, plus millions
of poultry, cattle, swine, sheep, and minor animal species.
(Minor animal species include animals other than cattle, swine,
chickens, turkeys, horses, dogs, and cats.)
Pets are very important to all people including the
elderly. CVM has approved drugs that may make it easier for
elderly to keep their pets. CVM approved two drugs to treat two
different behavioral problems affecting some dogs--Clomicalm
Tablets (clomipramine hydrochloride) to be used as part of a
comprehensive behavioral management program for separation
anxiety in dogs greater than six months of age, and Anipryl
Tablets to control the clinical signs associated with canine
Cognitive Dysfunction Syndrome (CDS).
Separation anxiety is a complex behavior disorder displayed
when the owner or someone the dog is attached to leaves the
dog. Dogs with separation anxiety may exhibit one or more of
the following symptoms: barking, destructive behavior,
excessive salivation, and inappropriate elimination.
Anipryl Tablets can control the clinical signs associated
with CDS, an age-related deterioration typified by multiple
cognitive impairments that affect the dog's ability to function
normally. Behavioral changes associated with CDS include
disorientation, decreased activity level, abnormal sleep wake
cycles, loss of house training, decreased or altered
responsiveness to family members, and decreased or altered
greeting behavior.
Public Affairs Specialists
Public Affairs Specialists (PASs) are located throughout
the country in FDA field offices. PASs participate in diverse
outreach activities to update and educate the Agency's
stakeholders on a multitude of important public health issues.
PASs also respond to consumer questions about the Agency, its
authorities, activities, and the products it regulates.The
Agency has established networks and communication channels to
reach the national and local aging network with consumer-
oriented information. By working with a variety of external
constituencies--consumers, patients, health professionals,
academia and scientific organizations, industry, women's
organizations, minority groups, and the international
community--FDA is able to form the collaborations and
cooperative arrangements to significantly extend its outreach
to older consumers.
PASs have conducted a variety of community-based programs
in 1999-2000 to address the health concerns and information
needs of older Americans. The Agency also exhibits at major
annual meetings of national organizations, as well as at
community events and local health fairs sponsored by grassroots
organizations. The topics that were addressed by field
programs, exhibits, training activities, and speeches were food
labeling, food safety, safe use of medications, health fraud,
clinical trials, dietary supplements, drug approval, food and
drug interactions, and buying prescription drugs on the
Internet.
PAS (San Juan, Puerto Rico) participated in
a day long health fair targeting older persons and
members of the AARP.
PAS (Houston, Texas) participated in an
exhibit at the American Health Association ``Living
Longer-Living Well'' seminar. The event was designed to
guide women in taking wellness to heart by providing
health information on diet, stress reduction,
nutrition, and how disease affects the heart.
PAS (San Francisco, California) worked with
the local hospitals to provide workshop materials for
its ``Senior Medication Awareness Training Program.''
PAS (New Orleans, Louisiana) staffed an
exhibit at the ``4th Annual Mayor's Senior Summit.''
PAS (New Orleans, Louisiana) participated in
a ``Community Resources Sharing Forum'' sponsored by
the New Orleans Elder Action Coalition. The purpose of
the forum was to bring together key community leaders
to share information, ongoing programs, concerns, and
ideas. The PAS prepared FDA information packages.
PAS (Philadelphia, Pennsylvania) gave a
health fraud presentation to older Americans, older
American organizations, industry, and other federal
agencies.
PAS (Denver, Colorado) gave a presentation
on FDA's role and responsibilities in drug approval to
older Americans at the ``Prescription for Your Future''
conference.
PAS (Indianapolis, Indiana) gave a
presentation to a group of older Americans on FDA and
good nutrition for the elderly.
PAS (New Orleans, Louisiana) gave a
presentation on prevention and treatments for
osteoporosis and arthritis.
PAS (San Juan, Puerto Rico) gave a
presentation about the safe use of medications to a
group of retired consumers.
PAS (Parisippany, New Jersey) participated
in the 7th and 8th Annual Congressional Senior Expo.
Congressman Bob Franks sponsored this event in the hope
of connecting senior citizens of Central New Jersey
with the organizations and programs designed to serve
them.PASs regularly speak with media representatives,
give interviews and provide background information for
newspaper, magazine, newsletters, and television and
radio reporters.
PAS (Parisippany, New Jersey) worked with
the Glaucoma Foundation in developing an article on how
FDA reviews drugs and medical devices.
PAS (San Francisco, California) conducted an
on-camera interview with a local NBC station on how to
spot health fraud, a part of a series covering
fraudulent products and the elderly.
PAS (San Francisco, California) delivered a
food safety speech on the local Cable Network that
included information on microbiology, with a focus on
the four messages of the ``Fight BAC'' program.
PAS (New Orleans, Louisiana) taped a 30-
minute interview with the WSM Radio News Director on
the topics food safety for the holidays, drug
approvals, and stockpiling drugs.
For the last three years, CFSAN in cooperation with FDA's
Office of Regulatory Affairs has funded grassroots food safety
education projects proposed by FDA PASs emphasizing:
The Fight BAC! Campaign materials developed
by the Partnership for Food Safety Education;
National Food Safety Education Month;
Populations at severe risk from foodborne
illness (young children, older Americans, immuno-
compromised individuals);
People of low literacy or who primarily
speak languages other than English; and
Safe handling and preparation of raw shell
eggs and egg dishes.
The following projects geared toward older Americans were
funded by CFSAN in cooperation with FDA's Office of Regulatory
Affairs:
Development of education packets on Listeria
monocytogenes for use in training health professionals
working with at-risk populations in New York;
An island-wide campaign stressing egg safety
targeting at-risk populations, food service and retail
workers, and health professional in Puerto Rico;
Food safety and food allergy workshops in
Pennsylvania and Delaware for hospital, nursing home,
day care centers, and church food prepares;
Development and testing of methods for
improved communication of food recall and food safety
messages for at-risk populations;
Expansion of the train-the-trainer volunteer
program for senior food safety education to cover the
entire state of Florida; and
Food safety workshops for food preparers in
nursing homes, meals-on-wheels programs, and other
elderly nutrition sites in Douglas County, Wisconsin.
HEALTH CARE FINANCING ADMINISTRATION
HCFA Projects
Evaluation System for Medicare+Choice
Prj #: 500-95-0047/06
Start Date: 09/16/1998
End Date: 09/15/2001
Funding: $746,887
Vehicle: Task Order
PI: Lyle Nelson, Ph.D.
Awardee: Mathematica Policy Research, Inc.
PO: Brigid Goody, Sc.D
Description: The Balanced Budget Act of 1997 (P.L. 105-33)
makes several changes that affect the eligibility criteria for
and payment to health plans contracting with HCFA to provide
services to Medicare beneficiaries. The concurrent
implementation of several initiatives could have unintended
effects on the managed care choices available to Medicare
beneficiaries, as well as on the additional benefits provided
to beneficiaries and on the quality of care delivered to
beneficiaries enrolled in health plans. The purpose of this
task order is to design and implement a strategy for tracking
and evaluating managed care performance both nationwide and
within specific markets across the country during the
implementation of the Medicare+Choice provisions. Dimensions of
performance to be tracked include beneficiary access to managed
care options, as well as the cost and quality of services
delivered to beneficiaries by managed care organizations.
Status: Data preparation and analyses are ongoing. The
contractor has prepared exploratory case studies of 12 markets
and an interim report containing information on 69 markets
representing 74 percent of Medicare managed care enrollees.
Dimensions of performance included in these reports are the
availability of Medicare managed care organizations, enrollment
and disenrollment, and the variation and generosity of benefit
offerings. The principal findings of these preliminary analyses
indicate that early experience under varies substantially
across markets, especially with respect to contract nonrenewals
and the availability and generosity of prescription drug
benefits. Future analyses will include additional years' data
and expand the dimensions of performance to include access and
quality, provider behavior, and financial viability.
Next Generation Medicare Managed Care Payment System
Prj #: 500-00-0025/01
Start Date: 09/30/2000
End Date: 04/28/2002
Funding: $635,897
Vehicle: Task Order Contract
PI: Stuart Gutterman
Awardee: Urban Institute, The
PO: Leslie M. Greenwald, Ph.D.
Description: The purpose of this project is to design a
possible next generation payment methodology--currently called
the Direct Model--for the Medicare+Choice program. This study
will prepare a conceptual paper that describes and
operationalizes HCFA's proposed general approach. As of January
1, 2000, 10 percent of Medicare+Choice plans total capitated
payments are based on the Principle In-Patient Diagnostic Cost
Group (PIP-DCG) risk adjustment methodology. Future years will
see an increase in the proportion of payments based on risk
adjustment, with a comprehensive risk adjustment methodology
due to take effect in January 2004. The movement of the
Medicare+Choice program towards increased emphasis on health
status risk adjusted payments--though an improvement over
current demographic adjusted payments in terms of potential
accuracy and ability to address selection bias--still has a
significant drawback: it is based on FFS practice patterns and
costs. Two possible steps could be taken to separate Medicare
managed care payments from their traditional fee-for-service
basis. The first could be considered an interim approach, and
would address the problem of basing managed care payment on FFS
practice patterns. If a full encounter data model were
implemented, and if a complete set of data were mandated
(sufficient to support recalibration), risk adjuster weights
could be re-estimated using managed care encounter data (rather
than the FFS data used in the models development). In this way,
risk score weights and resulting predicted payments would
reflect actual managed care practice patterns instead of FFS
practice patterns. The remaining residual of FFS in the
approach would be FFS prices, which would be assigned to the
managed care encounter data in the absence of reliable
information on actual managed care costs. In the longer term,
HCFA could move to what could be called a direct payment model.
Under this direct model, managed care payments would move away
(all or in part) from their current county FFS basis. In this
direct payment approach, risk adjustment models could be
calibrated using either a combination of fee-for-service and
managed care encounter data, or managed care data alone. But
rather than converting enrollee expenditure estimates from risk
adjustment methodologies to a risk adjustment factor (i.e.
figures such as 1.05, indicating the estimated expenditures of
an individual relative to others), the risk adjustment model
would simply predict expected expenditures for that individual.
Then, this risk based estimated expenditure (inflated to the
payment year from the model calibration year) would be
multiplied by a geographic price index to adjust for local
price differences. In all likelihood, these price indexes would
continue to be based on prices observed in fee-for-service. It
might be possible however, in the future, to estimate both the
risk adjusted estimated expenditures and price indexes based on
costs/prices observed in managed care (or a combination of
managed care and fee-for-service). These concepts, however, are
not possible to implement today, when actual costs for managed
care services are all but unknown, and most national health
specific price indexes are considered weak. This model presumes
that the risk adjuster method would account sufficiently for
practice pattern variability. In addition, this change would
require agreement on the extent of parity between Medicare's
expenditures for beneficiaries enrolled in fee-for-service
versus managed care. This direct model could be summarized as
follows: Direct payment (Individuals Risk Based Estimated
Expenditures) x (Geographic Price Input). This possible future
approach for Medicare may seem extreme at first glance. But
because BBA had mandated that county rates by blended with a
national rate, there is already a move toward national pricing.
The direct model is perhaps a logical extension of this policy.
Status: In progress.
Survey of Medicare Beneficiaries Who Were Involuntarily
Disenrolled from HMOs that Withdrew from Medicare or Reduced
their Service Areas
Prj #: 500-95-0061/10
Start Date: 09/30/2000
End Date: 02/28/2002
Funding: $470,000
Vehicle: Task Order
PI: Bridget Booske
Awardee: University of Wisconsin--Madison/Research Triangle
Institute
PO: Gerald Riley
Description: In January 1999 and January 2000 about 100
HMOs withdrew from the Medicare program or reduced their
service areas. Over 300,000 Medicare beneficiaries were
disenrolled involuntarily each year, and had to enroll in
another HMO or go to fee-for-service (FFS). Many of these
disenrollees did not have another managed care plan available
to them. These beneficiaries had no choice but to go to FFS.
Most HMOs that participate in Medicare offer additional
benefits outside the regular Medicare benefit package. Extra
benefits commonly include low copayments, prescription drugs,
unlimited hospitalization, and preventive services. Many
beneficiaries have come to rely on the extra benefits they
receive from their HMO, particularly prescription drugs.
Replacing the benefits through Medigap insurance is usually
very expensive, and may be unaffordable for some. Joining
another HMO or going to FFS may also force many beneficiaries
to change doctors, creating dissatisfaction and disrupting
existing patterns of care. There has therefore been concern
among policymakers about the impact of the recent HMO
withdrawals on the beneficiary population. There have been two
efforts to assess the impact of the January 1999 withdrawals
and service area reductions on beneficiaries. The first, based
on survey results indicated that although most disenrollees
fared relatively well after their HMO withdrew from Medicare,
many experienced a reduction in supplemental benefits, an
increase in premiums, and/or disruption in their care
arrangements (Kaiser Family Foundation, 1999). Problems were
disproportionately experienced by disabled beneficiaries,
racial and ethnic minorities, the poor and near-poor, and those
reporting fair or poor health. The second effort covered
enrollee notification; information and assistance in exploring
new insurance options; what option beneficiaries selected;
changes in benefits and costs; problems encountered; and
satisfaction. HCFA anticipates that additional withdrawals may
occur in 2001 and subsequent years. It is desirable to know the
impact on beneficiaries if a significant number of additional
withdrawals occurs in 2001. In this project we will mount a
survey that asks about the experience of beneficiaries whose
plans withdraw from Medicare or reduce their service areas in
January, 2001. A draft survey instrument has been developed.
This project will: finalize the instrument; develop an OMB
clearance package; identify an appropriate sample from Medicare
administrative records; administer the survey; edit and clean
the data; analyze the survey responses; prepare a final report;
prepare and deliver a clean data file to HCFA for use in
further analyses. Beneficiaries will be asked what insurance
arrangements they made after their plan withdrew from Medicare
or reduced its service area; how their benefits and out of
pocket costs were affected by new arrangements necessitated by
their plan's withdrawal; and whether they had to change
doctors. The universe from which the survey sample will be
drawn is the Medicare population enrolled in managed care plans
that either terminate their risk contracts or reduce their
service areas in January, 2001. In the case of plans that
reduce their service areas, enrollees that live in areas from
which the plan withdraws will be eligible for the survey. The
survey sample must be drawn from 2 strata: persons who live in
geographic areas where at least one managed care plan is still
available under Medicare after January, 2001; and areas where
no Medicare managed care plans are available after January,
2001. Approximately 1,500 completed surveys must be produced
for each stratum. The survey must be conducted by mail with
telephone followup, and will consist of 20-30 questions.
Status: Research Triangle Institute is performing the work
under this task order with over 90 percent of the funds
assigned to their subcontract.
Updating the Johns Hopkins University ACG/ADG Risk
Adjustment Methods for Medicare Contracting
Prj #: 500-00-0060
Start Date: 09/29/2000
End Date: 03/31/2001
Funding: $272,902
Vehicle: Contract
PI: Jonathan Weiner
Awardee: Johns Hopkins University, School of Public Health
PO: Jesse Levy
Description: This contract will allow HCFA to better assess
and evaluate the Johns Hopkins University ACG/ADG model as an
option for a potential Medicare+Choice payment system. Johns
Hopkins will revise, extend and recalibrate the ADG/ACG model
using recent Medicare data. They will provide HCFA with the
updated software and a recalibration. Earlier work by Johns
Hopkins for HCFA updated the ACG/ADG Risk Adjustment Method for
application to Medicare risk contracting. In that project,
Hopkins developed two diagnosis-based risk adjustor models.
Work on these alternatives to the then existing demographic-
only risk adjustment models was concluded in 1996. In further
work entitled AApplying JHU ACG/ADG Risk Adjustment Methods to
Medicare Risk Contracting, Johns Hopkins further developed
their model for Medicare purposes. This concluded in early
2000.
Status: This project is getting underway.
Applying the Clinically Detailed Risk Information System
for Cost (CD-RISC) to Medicare+Choice Payments
Prj #: 500-95-0056/12
Start Date: 09/29/2000
End Date: 09/12/2001
Funding: $245,934
Vehicle: Task Order
PI: Emmitt Keeler
Awardee: RAND Corporation, The
PO: John Robst
Description: This project will provide technical consulting
and analytic services to assess and evaluate the Clinically
Detailed Risk Information System for Cost (CD-RISC) model as an
option for a potential Medicare+Choice payment system. The
project will calibrate the CD-RISC model on Medicare dataCwhich
may involve the need to make adjustments to the model as it
currently stands--and provide HCFA with the up to date software
and calibration. During earlier work funded by HCFA CD-RISC was
developed to potentially apply to capitation payments for the
under-65 population. This model has not yet been calibrated or
tested on Medicare beneficiaries and expenditures. In response
to our mandate from the Balanced Budget Act of 1997, HCFA has
implemented a risk adjustment method for Medicare+Choice
payments. That method relies on inpatient data only. For a
number of reasons, we believe methods that draw upon data from
outpatient care delivery sites as well as inpatient sites are
preferable to this model. We have announced that we plan to
implement a model that draws upon diagnoses from multiple sites
of care in 2004. We are now in the process of evaluating
different candidates among the models that have been developed
to see which ones perform the best. To make sure we have
sufficient choices available, we are funding further
development of contending models this one included.
Status: In progress.
Evaluation of the Competitive Pricing Demonstration--Phase
I
Prj #: 500-95-0048/07
Start Date: 06/30/1999
End Date: 08/29/2001
Funding: $458,288
Vehicle: Task Order
PI: Gregory C. Pope & Steven Garfinkel (RTI)
Awardee: Health Economics Research, Inc.
PO: Brigid Goody, Sc.D
Description: Section 4011 of the Balanced Budget Act of
1997, which establishes authority for HCFA to test competitive
pricing for Medicare+Choice organizations mandates that
``...the Secretary shall closely monitor and measure the impact
of the project on the price and quality of, and access to,
Medicare covered services, choice of health plans, changes in
enrollment, and other relevant factors.'' The purpose of this
phase of the evaluation of the Competitive Pricing
Demonstration is to provide HCFA with timely feedback on the
implementation and operational experience of each demonstration
site. A case study methodology will be used to develop both
qualitative and quantitative information required to assess the
strengths and weaknesses of the demonstration. The types of
questions to be answered during this phase include:
How was the bidding process implemented?
How did the plans react to the process?
Can the process be improved?
How smoothly was the demonstration implemented in
each site?
Were there operational problems for each of the
stakeholders and, if so, how were they resolved?
How effective were the Area Advisory Committees in
their responsibilities to advise on implementation
issues? What lessons were learned that could ease
implementation in other sites or on a nationwide basis?
Status: The contractor is currently completing a case study
of the advisory committee process. Since the implementation of
the demonstration has been delayed until January 2002, further
evaluation activities are being delayed. This delay will force
a change in this contract.
Evaluation of the Medical Savings Account Demonstration
Prj #:500-95-0057/06
Start Date: 09/28/1998
End Date: 09/27/2003
Funding: $6,546,119
Vehicle: Task Order
PI: Ken Cahill
Awardee: Barents Group, LLC/Westat
PO: Renee Mentnech
Description: This project evaluates the Medical Savings
Account (MSA) Demonstration. It compares the experience of MSA
enrollees with other Medicare beneficiaries. The contractor
will also act as a coordinator between HCFA and the
demonstration participants, including beneficiaries and health
plans, in order to ensure that accurate, reliable, and complete
data are collected.
Status: In progress.
Evaluation of the Medicare Choice Demonstration
Prj #:500-92-0011/06
Start Date: 09/01/1995
End Date: 09/30/2000
Funding: $1,591,240
Vehicle: Delivery Order
PI: Lyle Nelson, Ph.D.
Awardee: Mathematica Policy Research, Inc.
PO: Renee Mentnech
Description: HCFA is in the process of implementing the
Medicare Choices Demonstration to test the feasibility and
desirability of new types of managed care plans for Medicare
such as integrated delivery systems and preferred provider
organizations. This evaluation project provides a detailed
assessment of the overall demonstration project, which looks
specifically at beneficiary experiences in the demonstration,
cost and use of services within the demonstration sites, and
quality of care issues. The evaluation provides some insights
into whether the greater range of managed care options offered
in this demonstration would be more appealing to the Medicare
beneficiaries, and whether issues such as biased selection,
high rates of disenrollment, and dissatisfaction exist. In
addition, the evaluation project provides continuous monitoring
of the demonstration sites, including a comprehensive case
study of each of the managed care plans in the demonstration.
This part of the evaluation activities focuses on the
implementation experience and operational feasibility of the
new managed care plans, as well as how plans interact with
carriers and HCFA.
Status: The contractor has completed site visits to assess
the implementation difficulties the plans have encountered. The
first and second interim implementation reports are available.
A survey of plan enrollees and a fee-for-service comparison
group has also been completed. The survey focuses on reasons
for enrolling and disenrolling, enrollees' understanding of
their plans, and the enrollees' perceptions of access, quality,
and satisfaction. A final report is expected in the summer of
2000.
Department of Defense Subvention Demonstration Evaluation
Prj #:500-95-0056/06
Start Date: 09/03/1998
End Date: 03/02/2002
Funding: $1,411,439
Vehicle: Task Order
PI: Dana Goldman, Ph.D.
Awardee: RAND Corporation, The
PO: Leslie M. Greenwald, Ph.D.
Description: Under the demonstration, enrollment in the
Department of Defense's (DoD) Senior Prime plan is offered to
military retirees over age 65 who live within 40 miles of the
primary care facilities of one of the six sites, have recently
used military health facility services, and are enrolled in
Medicare Part B. The Senior Prime plans must meet all relevant
requirements for Medicare+Choice plans. Medicare makes a
capitation payment to DoD for each enrollee, and DoD must
maintain a level of effort for health care services to all
retirees who are also Medicare beneficiaries, whether or not
they choose to enroll, that is based on fiscal year 1996 DoD
experience. The evaluation seeks to answer the basic question:
can DoD and Medicare implement a cost-effective alternative for
delivering accessible and quality care to military-Medicare-
eligible beneficiaries? The evaluation will seek the answer by
examining issues in four basic areas:
Enrollment demand.
Enrollee benefits.
Cost of the program.
Impacts on other DoD and Medicare beneficiaries.
RAND is conducting a process evaluation and a quantitative
analysis for the demonstration sites and a set of control
sites.
Status: The final report from the evaluation was delivered
in April 1999. It is available from the National Technical
Information Service (NTIS) (accession number PB 99 149056). The
Interim Report conveying results of the process evaluation of
the demonstration start-up period was delivered in July 1999.
Second Generation of Social Health Maintenance Organization
Demonstration
Period: November 1996 Extended 30 months after the Report
to Congress is submitted.
Funding: Waiver-only.
Grantees: See below.
Description: In accordance with section 2344 of Public Law
98-369, the concept of a social health maintenance organization
(S/HMO) integrates health and social services under the direct
financial management of the provider of services. All acute-
and long-term-care services are provided by or through the S/
HMO at a fixed, annual, prepaid capitation sum. The Omnibus
Budget Reconciliation Act (BBA) of 1990 authorized the
expansion of the S/HMO demonstration. The purpose of this
second generation S/HMO (S/HMO-II) demonstration is to refine
the targeting and financing methodologies and the benefit
design of the current S/HMO model. The S/HMO-II model also
provided an opportunity to test more geriatrically-oriented
models of care. Six organizations in the project were selected
to participate. Only one plan is operational, The Health Plan
of Nevada. The Balanced Budget and Refinement Act of 1999
extended the demonstration until 18 months after the submission
of the SHMO transition Report to Congress. The Benefits
Improvement and Protection Act of 2000 further extended the
demonstration another 12 months, for a total of 30 months after
the submission of the SHMO transition Report to Congress.
Grantee: Health Plan of Nevada, Inc., P.O. Box 15645, Las
Vegas, NV 89114.
Period: September 1995-December 2001
Funding: $1,811,184
Contractor: Abt Associates Inc, 55 Wheeler Street,
Cambridge, MA 02138
Investigator: Henry Goldberg
Site Development and Technical Assistance for the Second
Generation Social Health Maintenance Organization Demonstration
Prj #:500-93-0033
Start Date: 09/27/1993
End Date: 12/30/2000
Funding: $2,251,123
Vehicle: Contract
PI: Robert L. Kane, M.D.
Awardee: University of Minnesota, School of Public Health,
Institute for Health Services Research
PO: Thomas Theis
Description: In January 1995, HCFA selected six
organizations to participate in the Second Generation Social
Health Maintenance Organization (S/HMO) Demonstration. The
purpose of this project is to study the impact of integrating
acute and long-term care services within a capitated managed
care system. It was developed to refine the targeting and
financing methodologies and the benefit design of the current
S/HMO model, which was initiated as a demonstration in 1985.
Although similar services are provided under both of these
demonstrations, the Second Generation S/HMO Demonstration
features a greater emphasis on geriatric care and a more
inclusive case-management system. Another distinguishing
characteristic of the project is its risk-adjusted payment
methodology that is based on an individual's health status and
functioning level. The primary focus of the project's
evaluation will be to compare beneficiaries enrolled in the
demonstration with beneficiaries in a section 1876 HMO program.
The University of Minnesota and its subcontractor, the
University of California at San Francisco, are providing
technical assistance and support in the development,
implementation, and operation of the Second Generation S/HMO
Demonstration.
Status: The developmental phase of the Second Generation S/
HMO Demonstration began in January 1995. Since that time the
University of Minnesota and the University of California at San
Francisco have been providing technical assistance to the
organizations participating in the project. They have also
developed a questionnaire that is being used to determine a
beneficiary's capitated payment rate, a series of geriatric
protocols is being used to help physicians identify and treat
certain health conditions, and a care coordination assessment
instrument is being used to assist case managers with care
planning. These technical assistance contractors have made site
visits during this time to review the progress of the S/HMO
site. They are also assisting a contractor in preparing a S/HMO
Transition Report to Congress. The Health Plan of Nevada (HPN)
began enrolling beneficiaries in the demonstration in November
1996. HPN enrollment at the end of 1999 was over 35,000
members.
Second Generation Social Health Maintenance Organization
Demonstration: Florida
Prj #:99-C-90874/4
Start Date: 05/01/1998
End Date: 06/30/2000
Funding: $150,000
Vehicle: Cooperative Agreement
PI: Charlie Liem
Awardee: Florida Department of Elder Affairs
PO: James Hawthorne
Description: This Cooperative Agreement provides the
Florida State Department of Elder Affairs (DEA) with funds to
purchase technical assistance and to support planning
activities for a second generation social HMO. The goal of this
project is to study the feasibility of implementing a Second
Generation Social HMO in Florida and, should this prove
feasible, to develop the specifications needed for the State to
issue an RFP.
Status: Department of Elder Affairs staff are taking the
lead in coordinating planning activities and have assembled a
task force comprised of consumers, providers, and
representatives from the Maryland State Department of Health
and Mental Hygiene to guide the planning process. They have
obtained Medicare and Medicaid claims data and are linking
these data in an effort to devise a rate-setting mechanism that
will work for plans that enroll a disproportionate share of
frail elderly.
Second Generation Social Health Maintenance Organization
Demonstration: Maryland
Prj #:99-C-90868/3
Start Date: 04/30/1999
End Date: 06/30/2000
Funding: $109,211
Vehicle: Cooperative Agreement
PI: Martin Wasserman, MD
Awardee: Maryland Department of Health and Mental Hygiene
PO: James Hawthorne
Description: This Cooperative Agreement provides the
Maryland State Department of Health and Mental Hygiene (DHMH)
with funds to purchase technical assistance and to support
planning activities for a second generation social HMO. The
state has sub-contracted this work to the Center for Health
Plan Development and Management (CHPDM) at the University of
Maryland in Baltimore County. The goal of this project is to
study the feasibility of implementing a Second Generation
Social HMO in Maryland and, should this prove feasible, to
develop the specifications needed for the State to issue an
RFP.
Status: The State has hired staff to coordinate planning
activities and has assembled a task force comprised of
consumers, providers, and representatives from the Department
of Health and Mental Hygiene to guide the planning process.
They have obtained Medicare and Medicaid claims data and are
linking these data in an effort to devise a rate-setting
mechanism that will work for plans that enroll a
disproportionate share of frail elderly.
Evaluation of the Evercare Demonstration Program
Prj #:500-96-0008/02
Start Date: 09/26/1997
End Date: 03/25/2001
Funding: $1,544,142
Vehicle: Task Order
PI: Robert L. Kane, M.D.
Awardee: University of Minnesota
PO: Leslie M. Greenwald, Ph.D.
Description: For each EverCare site, of which there are
five, two comparison groups will be selected--nonparticipating
residents in EverCare site nursing homes and residents in
nonparticipating nursing homes operating in EverCare
demonstration cities.
Status: Site visits have been made to EverCare and non-
EverCare facilities in each of the participating sites. The
information gathered was developed into a paper that has been
submitted to the gerontologist for review.
Age Well Option (now referred to as TLC)
Prj #:18-P-90748/1
Start Date: 05/01/1997
End Date: 04/30/2002
Funding: $600,000
Vehicle: Grant
PI: Lewis A. Lipsitz, M.D.
Awardee: Hebrew Rehabilitation Center for the Aged
PO: Renee Mentnech
Description: Community care and educational protocols are
used to test the hypothesis that clients can be educated and
empowered to more actively participate in their own health care
planning, decisionmaking, and chronic disease management. The
populations studied are individuals living in the Hebrew
Rehabilitation Center for the Aged and those living in
subsidized housing in the Boston community. Educational
protocols are used to test the hypothesis that clients can be
educated and empowered to more actively participate in their
own health care planning, decisionmaking, and chronic disease
management.
Status: In progress.
On Lok's Risk-Based Community Care Organization for
Dependent Adults: On Lok Senior Health Services
Period: November 1983-Indefinite
Funding: Waiver only
Grantee: On Lok Senior Health Services, 1333 Bush Street,
San Francisco, CA 94109 and California Department of Health
Services, 714-744 P Street, P.O. Box 942732, San Francisco, CA
94234-7320.
Description::As mandated by sections 603(c) (1) and (2) of
Public Law 98-21, the Health Care Financing Administration
granted Medicare waivers to On Lok SeniorHealth Services and
Medicaid waivers to the California Department of Health
Services. Together, these waivers permitted On Lok to implement
an at-risk, capitated payment demonstration in which more than
300 frail elderly persons, certified by the California
Department of Health Services for institutionalization in a
skilled nursing facility, are provided a comprehensive array of
health and health-related services in the community. The
current demonstration maintains On Lok's comprehensive
community-based program but has modified its financial base and
reimbursement mechanism. All services are paid for by a
predetermined capitated rate from both the Medicare and
Medicaid (Medi-Cal) programs. The Medicare rate is based on the
average per capita cost for the San Francisco county Medicare
population. The Medi-Cal rate is based on the State's
computation of current costs for similar Medi-Cal recipients,
using the formula for prepaid health plans. Individual
participants may be required to make copayments, spenddown
income, or divest assets based on their financial status and
eligibility for either or both programs. On Lok has accepted
total risk beyond the capitated rates of both Medicare and
Medi-Cal. The demonstration provides service funding only under
the waivers. Research and development activities are funded
through private foundations.
Section 9220 of Public Law 99-272 extended On Lok's Risk-
Based Community Care organization for Dependent Adults
indefinitely, subject to the terms and conditions in effect as
of July 1, 1985, with the exception of the requirements
relating to data collection and evaluation. On Lok is continued
to collaborative projects with other organizations in the San
Francisco Bay area. A pilot agreement with the Institute on
Aging (IOA) was completed and the two organizations have
entered into a venture agreement in which IOA established an
adult day health center, operating it under the rules of the
program of All-Inclusive Care for the Elderly (PACE) protocol.
The site is in the Richmond area of San Francisco. On Lok
provides quality assurance oversight as well as marketing and
enrollment support. IOA receives a portion of On Lok's
capitation via the HCFA demonstration and a portion is retained
by On Lok to cover administrative expenses. The Balanced Budget
Act of 1997 authorized coverage of PACE under the Medicare
program. Under the Benefits Improvement and Protection Act of
2000, this demonstration has until November 24, 2002 to
transition to operational
Status:. This date can be extended one year as a State
election.
Evaluation of the Program of All-Inclusive Care for the
Elderly (PACE)
Prj #:500-96-0003/04
Start Date: 04/23/1997
End Date: 06/30/2000
Funding: $238,917
Vehicle: Task Order
PI: David Kidder, Ph.D.
Awardee: Abt Associates, Inc.
PO: Frederick G. Thomas, III, CPA, MS, MBA
Description: The Evaluation of the Program of All-inclusive
Care for the Elderly (PACE) consists of both qualitative and
quantitative components. The purpose of the qualitative
component is to examine, in detail, the structure and process
of case management as well as to gain a better understanding of
the factors that drive interdisciplinary team decisionmaking in
the PACE model. Since enrollment in PACE has been lower than
originally expected, except for On Lok, the first part of the
quantitative part of the evaluation of PACE is examining the
decision to participate in PACE. This is particularly important
given the anomaly of under-enrollment in virtually all long-
term care alternatives, as well as the policy interest in
encouraging increased use of managed care. In the evaluation,
the process by which people come to participate in PACE is
modeled. The ``refusers,'' or those who apply to PACE and pass
the initial screening eligibility criteria but do not actually
enroll in the program, serve as the comparison group for the
evaluation of the impact of PACE. The impact evaluation of PACE
is addressing a broad range of questions including:
Does the government spend less on PACE clients than
it would have spent on them in the absence of PACE?
Does the PACE program spend no more on PACE clients
than the capitation amount?
Does PACE alter the mix of services provided?
Does the quality of life and satisfaction with
services increase for participants and family members?
Does PACE impact the presence and amount of formal
in-home care, formal care outside the home, informal
in-home care and informal care outside the home?
How does PACE affect the health status and functional
status of PACE participants?
Status: All of the data collection for this project has
been completed and the contractor is analyzing the impact of
PACE on Medicare costs. A final report, entitled ``The Impact
of PACE on Participant Outcomes,'' has been received. Briefly,
this study found that compared to the comparison group:
PACE enrollees had much lower rates of nursing home
and inpatient hospital utilization, and higher rates of
ambulatory care.
PACE enrollees reported better health status and
quality of life.
PACE participants had lower mortality rates.
The benefits of PACE appeared to be magnified for those
participants with high levels of physical impairment. Work
continues on the study of the cost effectiveness of PACE.
Actuarial Assessment of PACE Enrollment Characteristics in
Developing Capitated Payments
Prj #:500-95-0061/09
Start Date: 09/30/2000
End Date:
Funding: $120,460
Vehicle: Task Order
PI: James Robertson
Awardee: University of Wisconsin--Madison/Research Triangle
Institute
PO: Frederick G. Thomas, III, CPA, MS, MBA
Description: The purpose of this is to investigate the
impact of a number of the Program for All-Inclusive Care for
the Elderly (PACE) specific issues on financial risk and
payments and then to formulate alternative payment options,
which would result in a reasonable approach for Medicare
payments to PACE. The BBA requires the PACE program to be paid
using the risk adjustment method developed for Medicare+Choice
programs, but adjusted for factors specific to the PACE
program. PACE is expected to differ from M+C plans in a number
of attributes: enrollment size, group bias, dual Medicaid
capitation, and mortality rates. An actuarial assessment is
needed to explore the risk characteristics related with these
factors and to formulate options that use this information in a
capitated payment system. The project will explore the
following issues related to PACE payments: (1) The Problem of
Small Numbers--The volatility of a PACE site's average actual
Medicare service costs for a period depends upon the site's
census. Enrollment size could influence: (a) setting the
minimally viable number of PACE organizations in a geographic
area, (b) setting the minimum enrollment size for a viable PACE
site, and (c) establishing financial reserve requirements,
which may be considered by licensing agencies in assessing
financial viability. Large sites should exhibit more stable
per-member-per-month costs from period to period than smaller
sites. So, all else being equal, smaller sites will be more
likely than large sites to experience significant strains on
their financial status. In the insurance industry, this
exposure is managed through reinsurance agreements or minimum
surplus requirements. The actuarial topic of ruin theory may be
applied to determine the formula for the minimum surplus level
to assure that the probability of a site's financial ruin is
less than some maximum tolerance. (2) Biased Groups--Related to
the problem of small numbers, PACE organizations enroll an
inherently biased group of beneficiaries. Available studies
suggest that PACE enrollees are sicker, frailer, and more
costly than the average Medicare beneficiary is. It is not
clear whether these higher costs are driven by enrollment into
PACE after a precipitating event, or if these costs are ongoing
as a result of enrolling patients with chronic/persistent
illnesses. Either bias would likely act to increase the
financial risk assumed by PACE organizations particularly in
light of the assumption of a random draw in Medicare+Choice,
where payment is based on the average. However, the rate
setting implications are different. If PACE is enrolling
beneficiaries at a high point their expenditure pattern, then
remaining expenditures prior to enrollment could overstate
average costs. On the other hand, paying average cost will
underpay given the lingering effects of the precipitating event
and higher costs in the last year of life. What is the most
appropriate Arisk adjuster or other method of modifying
capitation rates to account for these biases? (3) Medicaid
Capitation--Ignoring the adequacy of the Medicaid rates, does a
jointly capitated payment model reduce the financial risk to a
PACE organization? This could occur if services provided by
Medicare result in lower Medicaid costs. (4) Higher Mortality--
PACE organizations have experienced higher mortality rates,
estimated at roughly 20 percent per year. A prospective model
is used in Medicare+Choice payments; however, the mortality is
much lower, estimated at 3 percent. If a prospective risk
adjustment model is used, payments will be adjusted in
subsequent years only on living enrollees. Given the
differential rates in mortality, would a prospective payment
model adjusted for higher mortality result in lower financial
risk to a PACE organization?
Status: Payments for medical services furnished by PACE
organizations are fully capitated by Medicare and Medicaid. A
variant of this capitated approach is used by Medicare to pay
Medicare+Choice organizations, which generally have much larger
numbers of Medicare participants than PACE organizations.
Because of their unique niche, total reliance on capitated
payments (Medicare and Medicaid), lower enrollee levels, and
higher mortality rates, PACE organizations may have a higher
level of financial risk than Medicare+Choice plans. In order to
assess the potential risk elements as well as to help determine
implications for policy purposes, an actuarial evaluation and
assessment of payment rates for PACE will be performed under
this project. Available studies suggest that PACE enrollees are
sicker, frailer, and more costly than the average Medicare
beneficiary. It is not clear whether these higher costs are
driven by enrollment into PACE after a precipitating event, or
if these costs are ongoing as a result of enrolling patients
with chronic/persistent illnesses. Either bias would likely act
to increase the financial risk assumed by PACE organizations
particularly in light of the assumption of a random draw in
Medicare+Choice, where payment is based on the average. This
project will assess the financial risk that PACE organizations
incur as a result of their smaller enrollment numbers, biased
populations, and higher mortality. Risk will be characterized
in enrollment level tiers and compared and contrasted to the
risk characteristics of larger health delivery organizations.
Simulations and the actuarial theory of ruin will be used in
this assessment. The impact of joint capitated funding streams
(Medicare and Medicaid) also will be modeled. Available claims
data and data sets from other studies will be analyzed under
this contract.
Community Nursing Organization Demonstration
Period: September 1992--December 31, 2001
Contractors: See below.
Description: Section 4079 of Public Law 100-203 directs the
Secretary of the Department of Health and Human Services to
conduct demonstration projects at four or more sites to test a
capitated, nurse-managed system of care. The two fundamental
elements of the Community Nursing Organization (CNO)
demonstration are capitated payment and nurse case management.
These two elements are designed to promote timely and
appropriate use of community health services and to reduce the
use of costly acute care services. The legislation mandates a
CNO service package that includes home health care, durable
medical equipment, and certain ambulatory care services. Four
applicants were awarded site demonstration contracts on
September 30, 1992. The selected sites represent a mix of urban
and rural sites and different types of health providers,
including a home health agency, a hospital-based system, and a
large multi speciality clinic. All CNO sites underwent a 1-year
development period and began a 3-year operational period in
January 1994. The Balanced Budget Act of 1997 extended the
demonstration through December 31, 1999. The Balanced Budget
and Refinement Act of 1999 extended the demonstration through
December 2001 and inlcuded a budget neutrality requirement for
the payment rates. The Benefits Improvement and Protection Act
of 2000 removes the budget neutrality reqirement but will
reduce projected payment rates by 15 percent for the New York
site, and 10 percent for the three other sites. Actuarial
adjustments will also be made for October through December 2000
and for calendar year 2001. Abt Associates Inc. was selected to
evaluate the project and to provide technical assistance to the
sites. Abt Associates Inc also was awarded the external quality
assurance contract.
Contractor: Care Clinic Association, 307 East Oak, Suite 3,
P.O. Box 718, Mahomet , IL 61853.
Contractor:Visiting Nurse Service of New York, 107 East
70th Street, New York, NY 10021-5087
Aditional Analyses of Community Nursing Organization (CNO)
Demonstration Data
Prj #: 500-95-0062/09
Start Date: 09/29/2000
End Date: 01/19/2001
Funding: $204,637
Vehicle: Task Order
PI: Steven Pizer
Awardee: Abt Associates, Inc.
PO: James Hawthorne
Description: The Community Nursing Organization (CNO)
Demonstration was mandated by the Omnibus Budget Reconciliation
Act of 1987, although actual enrollment did not commence until
12/17/93. The demonstration was originally authorized for three
years but in 1996 it received a one-year extension from HCFA,
followed by a two-year extension through the Balanced Budget
Act of 1997. The demonstration was scheduled to end on 12/31/
99, but received another two year extension from Congress in
the Balanced Budget Refinement Act of 1999 (BBRA). It is now
scheduled to run until 12/31/01. Abt Associates was contracted
to design and conduct an evaluation of the first phase of the
demonstration. The Abt Phase I evaluation included
beneficiaries randomized through September 1995. It addressed
the experience of these beneficiaries through the beginning of
1997. The main findings were that the CNO intervention did not
significantly improve care and that capitation payments to the
CNO's were significantly higher than expenditures for the same
package of services provided to the control groups but paid for
on a fee-for-service basis. Because of language in the BBRA,
which requires that the remainder of the demonstration be
budget neutral, and the findings from the Abt evaluation, HCFA
notified the CNO sites that their capitation payments will be
reduced. The CNO sites and Congressional staff contend that the
payment reductions are such that the CNOs will be required to
cease operations. As a result of requests from the CNO sites
and Congressional staff, several meetings took place to discuss
the future of the demonstration and the budget neutrality
requirement. The CNO sites and Congressional staff question the
validity of the Abt evaluation and have requested that
additional analyses be conducted. The CNO sites and
Congressional staff are particularly concerned about the fact
that in a 1998 Interim Report by the evaluation contractor, the
expenditures for the treatment and control groups were
different than the expenditure amounts in the Final Evaluation
Report. Several important methodological changes were made in
the Final Report, including the elimination from the analysis
of participants from the treatment group who enrolled after
randomization stopped, the addition of 6 more months of data,
and the use of an inflation adjustment that was not applied to
the data in the Interim Report. The CNO sites and Congressional
staff want to know the extent to which each of these
methodological changes affected the expenditure amounts in the
Final Report. They want to have a better understanding of the
reasons behind the changes between the Interim and Final
Reports. When the evaluation contractor conducted the work for
the Final Report, they re-constructed the files from scratch,
which means the Final Report was not simply an update of the
analyses in the interim report. Therefore, to fully understand
the differences between the Interim and Final Report and answer
their questions and concerns, additional programming and
analyses will be necessary.
Phase II Evaluation of Community Nursing Organization (CNO)
Demonstrations
Prj #: 500-95-0062/10
Start Date: 09/20/2000
End Date: 09/19/2002
Funding: $246,367
Vehicle: Task Order
PI: Steve Pizer
Awardee: Abt Associates, Inc.
PO: James Hawthorne
Description: This project is for the design and
implementation of the Phase II evaluation of this ongoing
demonstration. The Community Nursing Organization (CNO)
Demonstration was mandated by the Omnibus Budget Reconciliation
Act of 1987 although actual data collection for the project did
not commence until 12/17/93. The demonstration was originally
authorized for three years but in 1996 it received a one-year
extension (from HCFA)(followed by a two-year extension
authorized in the Section 10019 of the Balanced Budget Act of
1997). The demonstration was scheduled to end on 12/31/99 but
(in Section 532 of the Balanced Budget Refinement Act of
1999(BBRA)) it received another two year extension from
Congress and is now scheduled to run until 12/31/01. Abt
Associates won a competitive contract to design and conduct an
evaluation of the first phase of the demonstration. The Abt
(Phase I) evaluation covers the operation of the demonstration
from January, 1994 to July, 1997. In addition to extending the
demonstration, Congress mandated a second evaluation of the
demonstration which is this Phase II Evaluation. A final report
of this evaluation is to be delivered to Congress no later than
7/1/01. This new/extended evaluation will provide for longer
term follow-up of early participants and will also include
assessment of the effects of the CNO intervention on later
participants whose data were not available for the Abt
evaluation. This second evaluation will require the use of HCC
concurrent, risk adjusted estimates of Medicare expenditures
for Medicare beneficiaries who participated in the
demonstration as well as for a new comparison group. The
calculation of the risk adjuster scores is being contracted
separately and the resulting data will be made available to
this Phase II Evaluation.
Study of Pharmaceutical Benefit Management
Prj #: 500-97-0399
Start Date: 09/28/2000
End Date: 07/13/2001
Funding: $299,695
Vehicle: Contract
PI: Michael Keagan
Awardee: PriceWaterhouse Coopers, LP
PO: Peri H. Iz, Ph.D.
Description: This study is an extension of an earlier HCFA
ORD research (500-95-0065/02). Completed in 1996, this early
study remains valuable for its description of the industry
functions and the origins. However, most information contained
in the early study is no longer current. This industry has
undergone major stages of evolution during the past five years.
While the industry size has grown impressively in size, there
has been an increasing concentration of market power. The
pharmacy benefit management (PBM) industry is becoming a
dominant player in the administration of pharmaceutical
benefits. It seems certain that the PBM sector will play a
significant role in administering the Medicare program in case
a drug benefit is added to Medicare. This study will
systematically examine this growing PBM industry from a
potential client's perspective.
Status: The project is in the start-up phase.
Evaluation of Programs of Coordinated Care and Disease
Management
Prj #: 500-95-0047/09
Start Date: 09/30/2000
End Date: 09/29/2005
Funding: $3,018,839
Vehicle: Task Order
PI: Randolph Brown
Awardee: Mathematica Policy Research
PO: Barbara Silverman, MD
Description: This project will design and conduct the
evaluation of a group of Congressionally mandated demonstration
programs and two HCFA-initiated demonstration programs. These
programs will test various methods of managing care in the fee-
for-service Medicare environment. Attempts to demonstrate the
effectiveness of programs of care coordination or management
are complicated not only by wide variations in program staff,
funding mechanisms, interventions and stated goals, but by the
evaluator's definition(s) of effectiveness. Despite the
widespread acceptance of the concept of care coordination,
studies of the effectiveness of various approaches, including
those conducted in Medicare beneficiary populations, have
yielded mixed results. The results of a Medicare demonstration
of case management in a fee-for-service environment carried out
from October 1992 through November 1995 are demonstrative of
the difficulties inherent in defining and evaluating the
effectiveness of these programs. The three programs studied
varied widely in their target populations and the nature of the
interventions attempted; although all were associated with
increased client satisfaction, none appeared to improve
outcomes or reduce costs. A major defect in the three programs
studied was a lack of active involvement of the primary care
provider in the case management intervention. HCFA continues to
investigate the potential of care coordination or case
management to improve care quality and control costs in the
Medicare fee-for-service program. Section 4016 of the Balanced
Budget Act of 1997 (Public Law 105-33) required the Secretary
to design a demonstration of approaches to coordinated care of
chronic illnesses in up to nine separate sites. As required by
Congress, an evaluation of best practices in coordinated care
and a study of demonstration design options has been conducted.
A solicitation informing interested parties of the intent to
conduct this demonstration is expected in late Spring, 2000.
Demonstration sites will be funded for a period of four years.
A separate demonstration, the Medicare Case Management
Demonstration, focuses on programs of case management specific
to diabetes and congestive heart failure. This evaluation is to
assess the effectiveness of various strategies for coordinating
care in the fee for service (FFS) Medicare environment, in a
total of 11 demonstration sites. The participating
demonstration sites will vary considerably by a number of
factors, including corporate structure, types of medical
conditions addressed, scope of patient care covered,
beneficiary eligibility, source of comparison data. However,
the sites have in common the goal of improving quality and
reducing cost of health care received by chronically ill
Medicare beneficiaries through any or all of the following: 1.
Individualized plans of care that take into account the
beneficiaries medical and social needs. 2. Improved
beneficiaries access to treatment and prevention services,
including services that may not otherwise be available through
the traditional Medicare fee-for-service program (such as
medications, home visits, transportation, and health
education). 3. Involvement of a care Acoordinator@
or Amanager@ in the beneficiary medical care
depending on the design of the program, this individual may
exercise considerable control over the beneficiary's medical
care, or may function in an adjunct role, assisting patients in
making and keeping medical appointments, complying with
treatment recommendations and accessing other needed resources
4. Simplified processes for contacting providers to allow for
rapid resolution of new problems that otherwise might require
emergency care 5. Increased beneficiaries (or where applicable,
family members or caregivers) understanding of their medical
problems, in order to improve compliance with treatment plans.
6. Improved information sharing between health care providers
in order to insure that patients receive appropriate care in a
timely fashion, reduce duplicative or unnecessary care, and
avoid unnecessary emergency care and hospitalizations. The goal
of this evaluation is to identify those characteristics of the
programs of coordinated care under study that have the greatest
impact on health care quality and cost, and to identify the
target populations most likely to benefit from such programs.
The demonstration programs to be studied as a part of this
evaluation will vary widely with respect to the demographics,
medical and social situations of the target population,
intensity of services offered, interventions under study,
type(s) of health care professionals delivering the
interventions, and other factors. Furthermore, sites may be
added to the demonstration as it progresses. For these reasons,
the evaluator will be required to establish a basic framework
for analysis that can be tailored to the requirements of each
demonstration site, and will allow for between-site comparisons
at the intervals and at the completion of the evaluation.
Status: In progress.
Aging in Place: A New Model for Long-Term Care
Prj #: 18-C-91036/7
Start Date: 06/18/1999
End Date: 06/17/2003
Funding: $1,169,406
Vehicle: Cooperative Agreement
PI: Karen Dorman Marek, PhD, MBA, RN
Awardee: Curators of the University of Missorui, Office of
Sponsored Program Administration, University of Missouri--
Columbia, Sinclair School of Nursing
PO: Barbara Silverman, MD
Description: The goal of the ``Aging in Place'' model of
care for frail elderly is to allow elders to remain in their
homes as they age, rather than requiring frequent moves to
allow for more intensive care if and when it becomes necessary.
The University of Missouri's Sinclair School of Nursing is in
the process of implementing such a model. Although a planned
element of the program is a new senior housing development, the
program currently targets elderly residents of existing
congregate housing. The University has received a grant in the
amount of $2 million in support of the evaluation of this model
of care.
Status: A first-year award was made to the applicant
subject to revision of the study design and work plan according
to terms and conditions established by the review panel. HCFA
staff met with the Principal Investigator and other members of
the research team at a kick-off meeting on September 1, 1999,
at which time a revised work plan and budget were submitted. As
a result of changes to the study plan, the applicant requested
an increase in the first-year award with a corresponding
reduction in the Years 2-4 awards and no change in the total
budget. This change was approved.
Study of Medicare Payments in HPSA's
Prj #: 500-95-0056/11
Start Date: 09/21/1999
End Date: 07/29/2001
Funding: $240,323
Vehicle: Task Order
PI: Donna Farley
Awardee: RAND Corporation, The
PO: William Buczko, Ph.D.
Description:Medicare includes a number of special payment
provisions aimed at maintaining beneficiary access to needed
services in areas where there is a scarcity of physicians and
providers. These areas are designated by the Health Resources
and Services Administration and are called Health Professional
Shortage Areas (HPSAs). This project compiles data on trends in
payment amounts, services, and recipients that have been
provided by Medicare over the past decade, project future
trends, and suggests and assesses alternatives to the current
set of special payment provisions for HPSAs. It will review the
value of all Medicare payments to HPSAs for services provided
in, or to residents of, such areas. The methodology used to
designate such areas is undergoing proposed changes which are
expected to be finalized in the year 2000. This project will
inform HCFA about the importance of several Medicare special
payment policies for HPSAs and aid in the assessmentof them and
of alternatives.
Status: In progress.
Evaluation of Competitive Bidding Demonstration for DME and
POS
Prj #: 500-95-0061/03
Start Date: 09/30/1998
End Date: 05/15/2003
Funding: $2,315,249
Vehicle: Task Order
PI: Sarita Karon
Awardee: University of Wisconsin--Madison/Research Triangle
Institute/Northwestern Univ.
PO: Ann Meadow, Sc.D.
Description: HCFA has mounted a demonstration to test the
feasibility and effectiveness of establishing Medicare fees for
durable medical equipment (DME) and prosthetics, prosthetic
devices, orthotics and supplies (POS) through a competitive
bidding process. The fundamental objective of competitive
bidding is to use marketplace competition to establish market-
based prices and to select DME suppliers. The Balanced Budget
Act of 1997 (BBA) authorized competitive bidding demonstrations
for Part B services (except physician services), and the
current project is being conducted under that authority. The
initial site of the demonstration is Polk County, Florida.
Competitively bid product categories in Polk include oxygen
supplies and equipment, enteral nutrition, surgical dressings,
urological supplies, and hospital beds. Medicare contracts with
winning suppliers commenced in October 1999. Section 4319 of
the BBA specifically mandates evaluation studies addressing
competitive bidding impacts on expenditures, quality, access,
and diversity of product selection. This task order will study
these and other outcomes of the demonstration. The evaluation
will use several types of research designs, such as multiple
time series analysis and pre-test/post-test comparisons. The
results of the evaluation will help HCFA decide how to conduct
any future competitive bidding activities.
Status: Data collection activities have begun. A pre-
demonstration survey of oxygen users and users of other medical
supplies was fielded in two Florida counties (Polk and Brevard)
in March 1999. The results suggested beneficiaries were highly
satisfied with the services and products delivered by their
Medicare suppliers. A followup survey is to be conducted during
CY 2000. Two site visits in 1999 were conducted as part of the
evaluation's case study activities, focusing on administrative
and market outcomes. Other evaluation activities now in the
planning stages include claims analyses, focus groups, fee-
schedule analyses, and additional surveys. The first annual
evaluation report is scheduled for release in early CY 2001.
Assessment of Medicare Prescription Drugs and Coverage
Policies
Prj #: 500-00-0024/01
Start Date: 09/30/2000
End Date: 02/28/2002
Funding: $202,527
Vehicle: Task Order
PI: Thomas Hoerger
Awardee: Research Triangle Institute
PO: Peri Iz
Description: The purpose of this task is to assemble and
analyze recent fee-for-service and managed care plan data on
Medicare spending for prescription drugs, as well as comparable
data from other public and/or private payers. Using these data,
the project will estimate possible financial effects of
alternative Medicare payment policies for drugs currently
covered by statute. This study will estimate current
expenditures and possible savings from alternative
reimbursement policies based on different discount rate and
price schedules used by other payers, as well as examine other
purchasing polices including competitive bidding and rebate
mechanisms. In fiscal year 1997, Medicare's limited
prescription drug benefits represented approximately 5 percent
($2.8 billion of the $56.4 billion) of the total Medicare Part
B expenditures. The majority of this drug spending is provided
on an inpatient basis or related to the End Stage Renal Disease
program. While not the most significant source of spending
under Medicare, Part B spending for these limited prescription
drugs exceeds spending for lens surgery, ambulance services, or
oxygen. Until recently, Medicare paid for these limited
prescription drugs based on reasonable charge determinations
for covered prescription drug products found in the published
Average Wholesale Price (AWP). Medicare paid 63 percent of the
amounts billed for prescription drug products and their
dispensing. A recent report from the Office of the Inspector
General (OIG) concluded, however, that Medicare's payments for
22 drugs in 1996 had an average mark-up of 41 percent over what
physicians and suppliers paid for the drugs. By contrast,
Medicare recognized only 49 percent of submitted charges for
all other billed Part B services. The Balanced Budget Act of
1997 changed Medicare's payment amount from 100 percent to 95
percent of the AWP. According to several OIG reports, public
programs such as Medicare have been paying too much for
prescription drugs relative to what pharmacies actually spend
for brand name products. For example, the prevailing Medicaid
discount rate has been 10 percent, whereas actual acquisition
discounts average over 18 percent. For generic products, the
disparity is thought to be larger. Medicaid recoups a
substantial portion of prescription drug payments through
rebates from manufacturers. Also, drug manufacturers frequently
provide special discounted prices for drugs used by the
Department of Defense, the Department of Veterans Affairs, and
certain Department of Health and Human Services health care
programs. In 1997, it was estimated that 68 percent of Medicare
managed care plan benefit packages included broadened benefits
for prescription drugs, and that some of these managed care
options were offered at no additional premium to beneficiaries.
Such managed care plans offering these options may receive
substantial discounts and/or rebates from manufacturers either
by negotiation or by use of pharmacy benefit management firms
who conduct price negotiations on behalf of plans. Medicare
would like to know in greater detail how its payment policy for
prescription drugs compares with the policies of other payers
and purchasers. But data for making such comparisons are not
readily available. HCFA does obtain detailed, product specific
data from state Medicaid programs that are used to calculate
rebate obligations of manufacturers. Under the terms of the
Medicaid rebate agreements, however, such data are held in
confidence and could not be used for this study. Hence, the
purposes of this study are twofold:
Data Collection (Task 1): the contractor will seek
and obtain available drug payment system information
from other non-Medicare organizations.
Comparative Analysis (Task 2): the contractor will
compare current Medicare covered prescription drug
reimbursement levels to those found in the data
gathered, and prepare an analytical report.
Status: In progress.
Examine the Effects of Providing a Outpatient Prescription
Drug Benefit
Prj #:HCFA-00-0046
Start Date: 01/20/2000
End Date: 02/28/2001
Funding: $15,000
Vehicle: Simplified Acquisition
PI: Ralph Monaco
Awardee: InterIndustry Economic Research Fund
PO: Edgar Peden
Description: This project analyzes the macro-economic
effects related to the introduction of a new public program,
specifically an outpatient prescription drug benefit for
Medicare.
Status: In progress.
Evaluation of the Nursing Home Case-Mix and Quality
Demonstration
Prj #:500-94-0061
Start Date: 09/30/1994
End Date: 09/01/2000
Funding: $2,980,219
Vehicle: Contract
PI: Robert J. Schmitz, Ph.D.
Awardee: Abt Associates, Inc.
PO: Edgar A. Peden
Description: Using data from the Nursing Home Case-Mix and
Quality (NHCMQ) Demonstration, HCFA is evaluating the new
practice of paying skilled nursing facilities (SNF) for
Medicare skilled nursing services on a prospective basis. Prior
to July 1, 1998, SNFs were reimbursed on a retrospective basis
for their reasonable costs. Since that date, however, following
methods used in the NHCMQ demonstration, a new prospective
methodology has been implemented. Under this methodology,
patients are classified into resource utilization groups which
are then used to calculate each facility's case mix. HCFA then
pays facilities for each covered day of care, to the case mix
of patients residing there on any given day. Though some costs
will continue to be
Status: Interim analyses of admitting patterns and select
outcomes have been undertaken, and visits to demonstration and
nondemonstration facilities have been completed which should
help in understanding provider response to the payment
demonstration. Data base construction and analysis of the third
phase of the demonstration, which bundled skilled therapy
services into the prospectively-paid routine rate has been
completed. This primary data collection activity was completed
in July 1999. MDS assessments were matched to Medicare SNF and
hospital claims and to HCFA Provider-of-Service records to
create the analytic data base for the project. Current analytic
activities center around assessing and revising the draft final
report. Of special interest is the analysis of primary data
regarding the provision of professional therapy services in
both demonstration sites and comparison sites.
Case-Mix Adjustment for a National Home Health Prospective
Payment System
Prj #:500-96-0003/02
Start Date: 07/26/1996
End Date: 09/30/2000
$Funding $3,416,984
Vehicle: Task Order
PI: Henry Goldberg
Awardee: Abt Associates Inc.
PO: Ann Meadow, Sc.D.
Description: The primary focus of this study is to
understand existing variation in home health resource patterns
and to use this information to develop a case-mix adjustment
system for a national home health prospective payment system
(PPS). In this study, the Outcomes and Assessment Information
Set (OASIS), which has been developed for outcome-based quality
assurance and improvement for Medicare home health agencies, is
being examined to see whether items included in this instrument
will be useful for case-mix adjustment. Detailed information,
including information on resource utilization and additional
items needed for case-mix adjustment not included on OASIS, has
been collected from participating agencies. (Arizona,
California, Florida, Illinois, Massachusetts, Pennsylvania,
Texas, Wisconsin.)
Status: Ninety agencies were recruited and trained from
eight States in the spring and summer of 1997. All agencies
began data collection on a 6-month cohort of new admissions to
home care beginning in October 1997. Data collection ended in
the spring of 1999. Analysis to date has resulted in a viable,
clinically coherent system of 80 case-mix groups that explains
more than 30 percent of the variation in resource use on a
development sample drawn from the cohort members. Resource use
is measured for 60-day periods of care, to conform to the
planned unit of payment under the forthcoming national PPS.
Selected OASIS assessment items, collected at the start of
care, are used in the grouping system. The case-mix items fall
into three major domains: clinical factors, functional-status
factors, and utilization factors. Within each domain, a
parsimonious set of items is summarized into a score for the
patient. In two of the domains, scores are partitioned into
four levels corresponding to high, moderate, low, and minimal
impact, based on the relationship of the score to resource
utilization. In the third domain, scores are partitioned into
five impact levels. A patient's combination of levels on all
three domains identifies the group into which the patient is
classified for purposes of case-mix adjusting the prospective
payment amount. Under this system, the patient's case mix
classification is updated at the end of the payment period to
reflect the actual amount of home therapy services received
during the 60-day payment period. This information is necessary
to arrive at a final score for the utilization domain. Results
of the study to date are described in two reports:
Case-Mix Adjustment for a National Home Health
Prospective Payment System: First Interim Report, July
1998 (revised December 1998).
Case-Mix Adjustment for a National Home Health
Prospective Payment System: Second Interim Report,
September 24, 1999.
Additional reports on model validation results refinement
related analysis and OASIS case-mix data verfication are
expected in 2001.
Maximizing the Cost Effectiveness of Home Health Care: The
Influence of Service Volume and Integration with Other Care
Settings on Patient Outcomes
Prj #:17-C-90435/8
Start Date: 09/01/1994
End Date: 09/30/2000
Funding: $1,496,245
Vehicle: Cooperative Agreement
PI: Peter W. Shaughnessy, Ph.D.
Awardee: Center for Health Policy Research, University of
Colorado
PO: Ann Meadow, Sc.D.
Description: Home health care (HHC) is the most rapidly
growing component of the Medicare budget in recent years. The
rapid growth in home health use has occurred despite limited
evidence about the necessary volume of HHC to achieve optimal
patient outcomes and whether it substitutes for more costly
institutional care. Little is known about integrating HHC with
care in other settings to reduce overall health care costs. The
central hypotheses of this study are that volume-outcome
relationships are present in HHC for common patient conditions,
that upper and lower volume thresholds exist that define the
range of services most beneficial to patients, and that a
strengthened physician role and better integration of HHC with
other services during an episode of care can optimize patient
outcomes while controlling costs. To test these hypotheses, a
sample of 3,600 patient records is being analyzed from agencies
in 20 States stratified into high, medium, and low-volume
categories based on annual visits per beneficiary. Trained data
collectors at each agency recorded patient health status and
service information between HHC admission and discharge to
assess patient outcomes and costs within the HHC episode. Long-
term, self-reported outcomes are being measured from telephone
interview data at HHC admission and from 6-month follow ups.
These primary data concerning patient status and outcomes will
be combined with Medicare claims data over the episode of care
to study the relationship between service volume in HHC and
both patient outcomes and costs.
Status: Study Paper 1, Research Design Update, which
summarized the research design and its evolution from the
original proposal, was finalized in September 1998. Primary
data collection ended in late 1998. An interim report on a
subsample of 1,000 patients (February 1999) described case mix
and volume relationships. Separately for the four common
conditions (congestive heart failure, stroke, surgical hip
procedures, and open wounds), a high- and low-volume group was
selected by taking the highest and lowest 45 percent of the
arrayed cases within each condition. Two-sample tests for mean
differences in case mix characteristics and volume were
performed to compare the two volume groups within each
condition. The median volume (defined as number of visits until
discharge or first inpatient admission) differed by a factor of
about four to nine, depending on the condition. For home health
aide services, mean volume differed by a factor of between 30
and 47. Many case mix indicators were measured at the start of
care. Of these, few demographic indicators differed between the
volume groups within condition. But limitations in activities
of daily living (ADLs) were significantly greater for the high-
volume groups, these patients had a greater prevalence of
chronic conditions, and their institutional utilization within
the 14 days prior to admission was less likely to be an acute-
care hospital, indicating the more post-acute nature of the
low-volume groups. This general case mix difference is
consistent with the greater use of aide services for high-
volume patients. Preliminary analyses of outcomes suggested
relatively few differences in outcomes by volume. This result
may mean that the additional services delivered to the high-
volume group helped equalize outcomes between more severely ill
and less severely ill patients. Risk-adjusted analyses planned
for later in the study are necessary to further explore this
possibility.
Evaluation of Phase II of the Home Health Agency
Prospective Payment Demonstration
Prj #:500-94-0062
Start Date: 09/30/1994
End Date: 09/30/2000
Funding: $3,528,408
Vehicle: Contract
PI: Barbara Phillips, Ph.D.
Awardee: Mathematica Policy Research, Inc.
PO: Ann Meadow, Sc.D.
Description: This contract is evaluating Phase II of the
Home Health Agency (HHA) Prospective Payment Demonstration,
under which HHAs are paid on a prospective basis for an episode
of care reimbursed by the Medicare program. (Phase I tested
per-visit prospective payment for HHAs.) Ninety-one agencies
from five states--California, Florida, Illinois, Massachusetts,
and Texas--were randomly assigned to either the treatment group
(prospective payment system (PPS) method, 48 agencies) or the
control group (conventional cost-based reimbursement, 43
agencies). The agencies phased into the demonstration at the
beginning of their 1996 fiscal year. Treatment-group agencies
can reduce the cost of care they provide during a 120-day
payment period by reducing visits, changing the mix of visits
to make less costly visits a larger proportion of visits,
reducing per-visit costs, or some combination of all three. The
cost-reducing activities raise the possibility that quality of
care might deteriorate under episode-based payment. Quality
impacts, along with cost, utilization, and qualitative,
behavioral effects, are the focus of the evaluation. The
findings will indicate not only the overall effects of the
change in payment methodology, but also how the effects are
likely to vary with the characteristics of agencies and
patients.
Status: Interim findings from the evaluation, based
primarily on the first 8 to 15 months of demonstration
operations, are described in following documents:
Transition Within a Turbulent System: An Analysis of
the Initial Implementation of the Per-Episode Home
Health Prospective Payment Demonstration, August 6,
1997.
Preliminary Report: The Impact of Prospective Payment
on Medicare Home Health Quality of Care, January 30,
1998.
Preliminary Report: The Impact of Prospective Payment
on Medicare Home Health Use--Promising Results for a
Future Program, July 22, 1998.
The Impact of Prospective Payment on Medicare Service
Use and Reimbursement During the First Demonstration
Year, December 1998.
Preliminary Report: The Impact of Prospective Payment
on the Cost per Episode: Striking the Balance Between
Decreasing Use and Increasing Cost, July 22, 1999.
Findings from the first 2 years of the evaluation are
described in additional reports forthcoming in calendar year
2000. Findings from the interim analysis of cost impacts
suggest that, on average, prospective payment reduced the cost
of care during the 120-day episode period by $419 or 13
percent. The impact on cost was similar across different types
of agencies, except that small agencies (less than 30,000
visits in year before the demonstration) exhibited a
significantly smaller effect than large agencies. Findings from
the utilization study suggest that the per-episode group of
HHAs was able to reduce the number of visits provided during
the 120-day episode period by 17 percent and the time from
admission to discharge by 15 percent. The proportion of
patients receiving care in each home health discipline changed
little under episode payment. The utilization findings
generally applied to agencies regardless of size, nonprofit
status, affiliation status (hospital or freestanding), or use
pattern (i.e., whether the agency provided more or less than
the average number of visits during a base year, given its case
mix).
The reduction in visits has not led to compensating
utilization in other parts of the health care system. An
analysis of utilization and reimbursement for Medicare-covered
services other than home health found that prospective payment
did not affect the use of or reimbursement for such services
during the 120-day episode period. An investigation of
spillover effects in settings not covered by Medicare similarly
found no compensating utilization. For example, prospective
payment did not affect the likelihood of receiving
nonresidential services such as personal care aides and adult
day care, based on results from a patient survey.
These findings suggest that a reduction in home health
utilization at the level observed under the demonstration does
not adversely affect care quality or shift costs to services in
other settings. Other interimanalyses of quality impacts found
few differences in patient outcomes between treatment and
control agencies, and when differences were found, they were
small. Analysis of claims data indicated that PPS patients have
significantly lower emergency room use. There were no
significant differences due to PPS in any other outcomes
studied from the claims data, including institutional
admissions for a diagnosis related to the home health care and
mortality. Results from the first patient survey on client
satisfaction suggested that both treatment and control group
clients were generally satisfied. On three specific components
of satisfaction with agency staff, treatment-group clients were
found to be somewhat less satisfied than control group clients,
although satisfaction levels were quite high in both groups.
Measures of health and functional outcomes from the survey
offered equivocal evidence for small negative effects of
prospective payment in a few of the functional outcomes. These
results are preliminary and require further study in a planned
follow-up survey. Half of the treatment agencies selected for
case study early in the demonstration reported plans for
specific initiatives to reduce per-episode costs spurred by
their participation in the demonstration project. From the case
studies, the evaluators concluded that treatment agencies were
not planning to change their behavior in ways that threatened
access or quality of care.
Subsequent evaluation reports will focus on utilization,
cost, and quality effects beyond the 120-day episode period.
There will be further case-study results on agency response to
the demonstration and an extension of previous work on cost
impacts to include an analysis of agencies' financial
performance. Finally, supplementary analyses will consider the
representativeness of the demonstration sample and the patient
selection behavior of agencies.
Medicare Post-Acute Care: Evaluation of BBA Payment
Policies and Related Changes
Prj #:500-96-0006/04
Start Date: 09/21/2000
End Date: 09/20/2002
Funding: $636,557
Vehicle: Task Order
PI: Brian Burwell
Awardee: MEDSTAT Group, LLC
PO: Philip Cotterill
Description: The purpose of this project is to study the
impact of BBA and other policy changes on Medicare utilization
and delivery patterns of post-acute care. Post-acute care is
generally defined to include the Medicare covered services
provided by skilled nursing facilities (SNFs), home health
agencies, rehabilitation hospitals and distinct part units,
long term care hospitals, and outpatient rehabilitation
providers. The changes in post-acute care payment policy
enacted in the late 1990's (mostly in the 1997 Balanced Budget
Act (BBA) with some subsequent modifications) were made one-by-
one to most types of post-acute care. However, a beneficiary's
post-acute care needs, can often be met in alternative provider
settings. Hence policy changes for one post-acute care modality
may have ramifications for other post-acute and acute care
services. Understanding the interrelationships among post-acute
care delivery systems is critical to the development of
policies that encourage appropriate and cost-effective use of
the entire range of care settings. The results of this work may
be useful in refining policies for individual types of post-
acute care, as well as in developing a more coordinated
approach across all settings. Medicare utilization and
expenditures for post-acute care increased dramatically in the
1990's prior to the passage of the BBA. Many of the changes
enacted in the BBA were in reaction to the experience of the
early 1990's and were aimed at controlling the decade's
fiscally disturbing expenditure trends. Even before passage of
the BBA, administrative actions (such as Operation Restore
Trust (ORT)) were taken to tighten the enforcement of coverage
guidelines and reduce abuses that were perceived to be
significant contributory factors to the runaway growth of the
early 1990s. Chief among the BBA changes was the mandate for
implementation of prospective payment systems to replace
retrospective cost-based payment for all the major post-acute
care providers. Among the BBA policies whose impacts to be
considered in this project are the following: the Interim
Payment System (IPS) for home health agencies; the SNF
prospective payment system; the revised inpatient hospital
transfer policy for 10 DRGs; the new cost limits and rebased
target amounts for rehabilitation hospitals and distinct part
units; and the outpatient therapy limits. Study Overview--In
general, the appropriate evaluation design is a Adifferences in
differences@ model that estimates differential
effects over time as a function of differential degrees of
impact. In this initial project, analyses will compare changes
between the pre-BBA period of the 1990's and a post-BBA year,
such as 1999. For the most part, the studies should focus on
the interrelationships among the various post-acute care
settings. However, in some cases, changes affecting a single
type of post-acute care may warrant special analysis. The model
needs to be applied flexibly to include a variety of
beneficiary, provider, and market area analyses. In addition,
analyses may involve data for individual years, as well as
changes between years. Since the impacts of policy changes not
yet implemented will continue to be of interest for many years,
the analyses developed under this project are expected to use
and refine methods that can be applied in future evaluation
research. Analytically, this is a challenging project due to
the numbers of provider types and policy changes involved. The
staggered and overlapping temporal implementation of the
changes further complicates the effort. The proposed analyses
are not necessarily expected to be able to attribute causality
to effects detected, nor are they expected to disentangle the
effects of one policy change from the effects of another. In
general, it will only be possible to determine net effects of
all changes relevant to a specific analysis. However, in
choosing time periods, attention will be paid to the policies
that could be expected to impact behavior during the period of
analysis. The project will utilize secondary data sources,
primarily HCFA claims data. Claims for all relevant types of
services will need to be linked with beneficiary enrollment
information to create Aepisodes@ of care by
beneficiary. At least 2 such episode files will be required,
one for a pre-BBA year such as 1995 or 1996 and another for a
post-BBA year such as 1999. In addition the project will design
a strategy for monitoring and evaluation of impacts across
post-acute care settings. We are interested in distinguishing
between the needs for regular monitoring of impacts across
post-acute care settings and more detailed evaluation studies.
We are especially interested in defining data requirements for
monitoring sentinel events that would serve as alerts for more
in-depth evaluation. The strategy will define data requirements
for monitoring and evaluation activities, taking into
consideration the data available for individual care modalities
and the need to integrate data across modalities in as timely
and efficient a manner as possible.
Status: In developmental phase.
Design of an Integrated Post-Acute Care System
Prj #: 500-96-0008/04
Start Date: 09/30/1997
End Date: 10/31/2001
Funding: $829,428
Vehicle: Task Order
PI: Robert L. Kane, M.D.
Awardee: University of Minnesota
PO: Frederick G. Thomas, III, CPA, MS, MBA
Description: HCFA intends to create an infrastructure of
post-acute and long-term care delivery and payment systems that
are better integrated and more flexible in meeting the needs of
beneficiaries with chronic illnesses and disabilities. The
transition from our current benefit and provider-based system
to a beneficiary-centered system requires several elements:
An assessment tool that can be used and shared across
provider types.
More flexible benefit packages.
Funding based on beneficiary health and functional
needs.
Case management that involves formal and informal
caregivers in care planning and supports and
encourages, where appropriate, beneficiaries to direct
their own care.
Additional work that incorporates beneficiary preferences
into outcome measures, as well as further attempts to
differentiate outcomes by post-acute-care modality for
different patient conditions, is also needed. The purpose of
this project is to design several elements needed in a more
integrated system--an assessment tool, potential case
management models, appropriate payment systems, and outcome
measures that cross settings and incorporate beneficiary
preferences, with the ultimate intent of pilot testing and
refining these elements in a demonstration. A second purpose of
this project is to design an optional demonstration that tests
the feasibility and effectiveness of creating a more integrated
post-acute-care system.
Status: Work has begun on developing potential case-
management models, as well as an assessment instrument.
Effects of Telemedicine on Accessibility, Quality, and Cost
of Health Care
Prj #:18-P-90332/5
Start Date: 07/01/1994
End Date: 09/30/2001
Funding: $644,086
Vehicle: Grant
PI: F. W. Womack
Awardee: University of Michigan
PO: Joel Greer, Ph.D.
Description: This project evaluated the effect of
telemedicine systems on accessibility, quality, and cost of
health care. A detailed methodology for evaluating telemedicine
was developed by a panel of experts and implemented in existing
telemedicine programs at the Medical College of Georgia (MCG)
Telemedicine Center and Mountaineer Doctor Television (MDTV) at
the Health Sciences Center, West Virginia University (WVU).
Included in the evaluation design was a quasi-experimental
survey study of clients and providers in selected experimental
and control communities and a case-control study to compare the
content, process, and outcomes of episodes of care with and
without telemedicine. The project plan had three goals:
Development of a detailed methodology for a comprehensive
evaluation of the effects of telemedicine on accessibility,
utilization, quality, and cost of health care, using a panel of
experts on quality, economics, clinical medicine, and
technology. Implementation and testing of the evaluation design
at the MCG Telemedicine Center. Extending the evaluation design
to MDTV at WVU.
The general hypothesis guiding this research was that
telemedicine will improve accessibility to health care, enhance
the quality of care delivered, and contain costs.
Status: The final report is being prepared.
Maximizing the Effective Use of Telemedicine: A Study of
the Effects, Cost Effectiveness, and Utilization Patterns of
Consultation via Telemedicine
Prj #: 18-C-90617/8
Start Date: 09/01/1995
End Date: 09/28/2002
Funding: $2,198,968
Vehicle: Cooperative Agreement
PI: Jim Grigsby, Ph.D. and Robert E. Schlenker, Ph.D.
Awardee: Center for Health Policy Research, University of
Colorado
PO: Joel Greer, Ph.D.
Description: This project is evaluating the medical
effectiveness, patient and provider acceptance, and costs
associated with telemedicine services, as well as their impact
on access to care in rural areas. The demonstration involves
ten rural hospitals, one rural referral hospital, and one urban
hospital. Planned services for the demonstration include
interactive video consults for teleradiology, telepathology,
and, where available, telesonography, electrocardiography, and
fetal monitoring strips. Payment for related physician services
is expected to be made under a waiver of Medicare payment
regulations. The goal of he project is to evaluate whether
specialty telemedicine services provided by hospital networks
produce change with respect to medical effectiveness, patient
and provider satisfaction, cost, and access. Hypotheses include
telemedicine improving differential diagnoses and treatment,
patients and providers being as satisfied with telemedicine as
with on-site services, telemedicine services being less costly
than on-site services, and telemedicine improving access to a
wider range of health care services.
Status: The evaluation design has been completed and the
instrument approved by the Office of Management and Budget.
Data collection has begun.
Evaluation of the Informatics, Telemedicine, and Education
Demonstration
Prj #: 500-95-0055/05
Start Date: 09/30/2000
End Date: 07/29/2004
$Funding $1,419,493
Vehicle: Task Order
PI: Judith Woodridge/Stephen Zuckerman
Awardee: Urban Institute, The
PO: Carol Magee
Description: Section 4207 of the Balanced Budget Act of
1997 (BBA97) instructs the Secretary to establish a single, 4-
year demonstration project using an eligible health care
provider telemedicine network. The demonstration involves the
application of high-capacity computing and advanced
telemedicine networks to the task of improvement of primary
care and prevention of health complications in Medicare
beneficiaries with diabetes mellitus. These beneficiaries must
reside in medically underserved rural or medically underserved
inner-city areas. The statute also mandates that the Secretary
submit a final Report to Congress (RTC) that: AY shall include
an evaluation of the impact of the use of telemedicine and
medical informatics on improving access of Medicare
beneficiaries to health care services, on reducing the costs of
such services, and on improving the quality of life of such
beneficiaries. Submission of the RTC is mandated by August 31,
2004 (6 months after the conclusion of the demonstration). The
purpose of this project is to evaluate the impact of the
Informatics, Telemedicine, and Education Demonstration Project
and to provide input into the RTC. The Informatics,
Telemedicine, and Education Demonstration project is using
specially modified home computers, or home telemedicine units
(HTU) linked to a Clinical Information System (CIS) maintained
by Columbia Presbyterian Medical Center. The HTUs in patients'
homes allow video conferencing, access to health information
and access to medical data. Computerized devices read blood
sugar levels, check blood pressure, take pictures of skin and
feet for signs of infection, and screen for other factors that
affect the management of diabetes. These data are fed
electronically to the data system at Columbia. The CIS provides
storage of clinical data for use in the development and
application of patient care guidelines and clinical standards.
Full-time nurse case-managers monitor the data and intervene if
the data from a patient vary from guidelines. Patients receive
feedback, including clinical data such as blood glucose levels,
care reminders and suggestions on how to maintain good health.
Health information specific to diabetes is to intervention
group participants on a specially developed website (under
development) in both low literacy and regular versions in both
Spanish and English.
The demonstration project is being conducted as a
randomized, controlled clinical trial. Half of the participants
are receiving the intervention, consisting of an HTU and
electronic services within a case-manager environment (as
detailed above), and half continue to receive usual care for
their diabetes. The demonstration consists of 2 components: an
urban component conducted in northern Manhattan, and a rural
component, conducted in upstate New York. Participants can have
either Type I or Type II diabetes, and both males and females
will be included. There are no racial or ethnic exclusions to
participation. Demonstration participants are being recruited
into the study over approximately 1 year. Once recruited and
randomized, each participant will remain in the demonstration
for 2 years. After completion of their time in the
demonstration, participants will be phased out over
approximately 1 year. Outcome data will be collected from all
participants at three visits (visit 1 [baseline], visit 2 [one
year follow-up], and visit 3 [two year follow-up]). The primary
health outcome measures to be collected as part of the
demonstration are glycosylated hemoglobin levels, blood
pressure levels, and lipid levels. Other important outcomes
include receipt of recommended diabetes-specific health care
services (dilated eye exam, foot exams), other recommended
preventive services, smoking cessation in the subset of
participants who smoke, and satisfaction with care.
Impact of the telemedicine intervention on health outcomes
will be evaluated by comparing mean and adjusted mean levels of
glycosylated hemoglobin, blood pressure, and lipids in the
intervention and the control groups. There will be two separate
analyses. The first is an internal analysis of the randomized
clinical trial to be conducted by the Columbia University
consortium analysts. The clinical trial analysis is primarily
focused on the impact of the telemedicine intervention on
health outcomes and clinical care of the participants. The
second evaluation, which is the this project, is to assess the
financial impact of the of the demonstration. This evaluation
is independent of Columbia's internal analysis. This financial
inpact evaluation will focus on whether the home telemedicine
intervention can increase access to care for Medicare
beneficiaries in medically underserved areas; whether the use
of the intervention would reduce health care costs; and whether
the physicians who are part of demonstration are representative
of the physician population serving Medicare beneficiaries.
More specifically, the questions to be addressed are:
What is the impact of the use of telemedicine and
medical informatics on:
access of Medicare beneficiaries to health care
services?
reducing the costs of health care services to Medicare
beneficiaries?
improving the quality of life of Medicare
beneficiaries?
In addition, issues to be addressed may include:
costs of the telemedicine intervention, with attention
to both technology and service costs of the
intervention
estimation of the cost-effectiveness of the
telemedicine interventiondifferences in the physicians
who participate in the demonstration from those who do
not participate.
Status: This project is subcontracted to Mathematica Policy
Research.
Design and Simulation of Alternative Medigap Structure
Prj #: 500-95-0059/07
Start Date: 09/30/1999
End Date: 07/29/2001
Funding: $588,984
Vehicle: Task Order
PI: Lisa Maria Alecxih
Awardee: Lewin Group, The
PO: John Robst
Description: While Medicare benefits are extensive, like
many insurance products, the program has deductible and co-
insurance requirements as well as limitations on payments to
providers. On average, basic Medicare benefits alone cover
about half the personal health care expenditures of aged
beneficiaries (Laschober and Olin, 1996). Because of these
``gaps'' in coverage, many beneficiaries choose to purchase a
supplemental policy, often called ``Medigap.'' The project will
compile premium data on existing standard Medigap premiums,
formulate alternative standard benefit packages, and estimate
premium costs of these alternative packages. From this
analysis, the current and alternative Medigap options will be
compared.
Though Medicare supplemental coverage has been available
since nearly the inception of the Medicare program itself,
prior to the enactment of the Social Security Disability
Amendments of 1980, such insurance products were regulated only
by States. Increasing concerns regarding the confusing array of
different Medigap products, questionable marketing and sales
practices, sales of overlapping and duplicative coverage, and
low loss ratios prompted Congress in 1980 to establish Federal
standards for Medigap plans. Most States adopted the standards,
which were developed by the National Association of Insurance
Commissioners. Continued concern regarding marketing abuses and
confusion among beneficiaries eventually prompted Congress to
mandate Medigap policy standards. As a result of the Omnibus
Budget Reconciliation Act of 1990, effective in 1992, newly
issued Medigap policies have been required to conform to one of
ten standardized benefit packages. The law also mandated other
standards, including minimum loss ratios and a guaranteed open
enrollment period for new Medicare enrollees. Despite many
changes in the Medicare programsince the early 1990s, the basic
benefit structure of Medicare supplemental insurance has
remained unchanged. This project will examine possible updated
Medigap benefit structures, and compare these alternatives to
the premiums and benefit structures of currently available
supplementary coverage, as well as Medicare+Choice options.
Status: In progress.
Health status and Medical Treatment of the Future Elderly:
Implications for Medicare Program Expenditures
Prj #:500-95-0056/09
Start Date: 06/30/1999
End Date: 06/15/2001
Funding: $1,582,650
Vehicle: Task Order
PI: Dana Goldman, Ph.D., and Michael Hurd, Ph.D.
Awardee: RAND Corporation, The
PO: Linda Greenberg, Ph.D.
Description: This project is designed to develop
demographic-economic models to project how changes in health
status, disease, and disability among the next generation of
the elderly will affect future Medicare spending. The goal of
this task order is to enable HCFA actuaries and policymakers to
simulate the impact of changes in health and functional status,
as well as changes in medical technology, on future costs to
the Medicare program. The first aim of the model will be to
answer the question: ``If the current trends in demographics
continue, and if the future generation of the elderly face the
same health status and health care environment as today's
elderly, what will future health care costs be?'' The second
aim of the model will be to serve as the simulation vehicle for
evaluating ``what if'' scenarios to explore how various
assumptions about changes in the health status of the elderly
and the health care environment will affect Medicare and non-
Medicare costs.
The models will focus on two key determinants of health
spending: diseases (and the medical technology to treat them)
and health status. RAND will use literature reviews and
technical expert panels (TEPs) to guide the model development
effort. The literature review effort will focus on five areas:
Health and disability trends.
New medical treatments.
Effects of new technologies on morbidity and
mortality.
Diseases most likely to affect the elderly's future
health expenditures.
Past efforts to model health care expenditures.
The first TEP--consisting primarily of physicians
knowledgeable about treatments for the elderly--will identify
conditions likely to affect expenditures by the future elderly.
For each condition, the TEP will identify the emerging
technologies and estimate likely consequences on mortality and
morbidity. The second TEP--consisting primarily of social
scientists and modelers--will help determine appropriate health
status measures, methodologies, and data sets for estimating
model parameters, and the best modeling techniques.
RAND will use a microsimulation model to estimate future
Medicare expenditures. The modeling efforts will consist of
three components: a ``basic'' model, a ``health status'' model,
and a ``what if'' model. The ``basic'' model will categorize
the future elderly population by age and sex, then iteratively
apply a transition matrix to calculate the status of the
population at later time periods. This will serve as a useful
benchmark for subsequent modeling efforts. The ``health
status'' model will augment the basic model to explicitly
include health status so that RAND can explore the possibility
that changes may occur in the health status of the elderly and
the treatment of particular health conditions among the
elderly. RAND will use longitudinal datasets to estimate the
transition rates--the probability that a person (or persons)
with certain demographic characteristics and known health
status will transition to another category with a different
demographic and health status description over some time
period. RAND will estimate the direct costs of health
expenditures by fitting parametric models of the distribution
of expenditures using existing data that link health status to
spending. Finally, the ``what if'' model will explore changing
the parameters of the health status model to reflect possible
changes to the health care environment, including medical
breakthroughs.
Status: The project is well underway. In September 1999, a
final design report was accepted. In the fall of 1999, project
staff consulted with nationally-recognized geriatricians to
discuss which disease groups and specific medical conditions
should be covered by the medical TEPs. Members have been
appointed to the medical and social science TEPs. Preliminary
reviews of the literature are expected prior to theTEP
meetings. Work on devising a micro-simulation model to estimate
future Medicare expenditures is underway. Final project results
are expected by December 2001.
Retiree Health Benefits
Prj #:500-95-0061/08
Start Date: 09/30/2000
End Date: 06/30/2002
Funding: $249,971
Vehicle: Task Order
PI: Lauren McCormack
Awardee: University of Wisconsin--Madison/Research Triangle
Institute
PO: Brigid Goody, Sc.D.
Description: This project examines current employer-based
health insurance coverage for Medicare-eligible retirees,
the prospects for continuation of this coverage and possible
implications for the restructuring of the Medicare fee-for-
service and Medicare+Choice (M+C) programs. Although
approximately one-third of aged Medicare beneficiaries have
coverage under an existing employer-sponsored health insurance
policy, the prevalence of coverage has declined and retiree
cost-sharing requirements have increased in recent years. If
current trends continue, the future of employer-sponsored
coverage of Medicare eligible retirees is not encouraging.
Declining employer-sponsored coverage could result in more
Medicare beneficiaries purchasing individual Medigap policies,
joining Medicare+Choice plans or going without supplemental
coverage. As Medicare beneficiaries face paying more for
services previously covered by retiree health insurance, the
Medicare Program may come under increasing pressure to offer
additional benefits, most notably outpatient prescription
drugs.
The project will consist of two parts. The first part will
analyze existing secondary data to describe the types of
coverage offered to Medicare-eligible retirees, the funding for
this coverage and recent trends in coverage. The second part
will be comprised of interviews aimed at understanding the
prospects for future employer-sponsored coverage of this
population, possible impacts of Medicare reform initiatives on
this coverage and how the Medicare Program, both fee-for-
service and managed care, might be restructured to encourage
continued coverage. Interviewees would, at a minimum, include
employers, unions, business coalition/purchasing groups and
outside consultants (insurance agents/brokers, third party
administrators and professional benefits consultants).
Status: Research Triangle Institute will perform this
project under a subcontract
Health Disparities: Longitudinal Study of Ischemic Heart
Disease Among Aged Medicare Beneficiaries
Prj #:500-95-0058/12
Start Date: 09/22/2000
End Date: 01/21/2002
Funding: $282,157
Vehicle: Task Order
PI: Jerry Cromwell
Awardee: Health Economics Research, Inc.
PO: Linda Greenberg, Ph.D.
Description: The purpose of this task order contract is to
assess the use of Medicare covered services among Medicare
beneficiaries with ischemic heart disease based on
sociodemographic characteristics (e.g., race/ethnicity, sex,
age, socioeconomic status). During the past few years, the
Health Care Financing Administration (HCFA) has undertaken
several efforts to strengthen the base of knowledge of health
disparities among racial/ethnic groups. This project is one
part of a larger HCFA and Department of Health and Human
Services effort to address health disparities among Medicare
beneficiaries. This will be done using a longitudinal database
that links Medicare enrollment and claims data with small-area
geographic data on income (e.g., U.S. Census data or other
private data sources). Such information will be useful to
compare the incidence of disease and the outcomes of diagnostic
and surgical procedures for ischemic heart disease (IHD) across
racial/ethnic groups, socioeconomic status, and geographic
areas. The advantage of a longitudinal database is that it
provides data at multiple time points during a person's life.
Due to recent expansions in the race/ethnic coding in the
Medicare enrollment database (EDB), it is now possible to
examine health care access, utilization, and outcomes among
minority groups.
Status: In progress.
Patterns of Injury in Medicare and Medicaid Beneficiaries
Prj #:500-95-0060/04
Start Date: 09/29/2000
End Date: 09/30/2001
Funding: $715,991
Vehicle: Task Order
PI: Deborah Garnick
Awardee: Brandeis University
PO: Rosemary Hakim, Ph.D.
Description: This project is a descriptive study of the
extent and impact of injuries in the Medicare and Medicaid
populations, and to conduct in depth analyses on specific types
of injuries. Unintentional injuries accounted for more than
90,000 deaths in the US in 1997, making this the fifth leading
cause of death overall. Intentional injuries, suicide and
homicide, have resulted in more than 50,000 deaths annually
since 1985. The impact on health care costs, income and
productivity is significant. Injuries may be an even more
important cause of mortality and morbidity among persons in
vulnerable populations, which include the populations served by
Medicare and Medicaid. While mortality data for injuries are
available, data addressing the prevalence of morbidity due to
injuries and the expenditures for related care are not
available. The Medicare and Medicaid data are particularly well
suited to assess morbidity due to injuries that are severe
enough to come to medical attention.
Status: In progress.
Examining Gender and Racial Disparities Among Medicare
Beneficiaries with Chronic Diseases
Prj #:500-95-0058/15
Start Date: 09/29/2000
End Date: 09/28/2001
Funding: $177,442
Vehicle: Task Order
PI: Deborah Dayhoff
Awardee: Health Economics Research, Inc.
PO: Marsha G. Davenport, M.D., M.P.H.
Description: The purpose of this task order is to develop
and complete an analytic study using the Medicare
administrative claims files to expand HCFA's knowledge base in
the area of women's health and chronic diseases. Chronic
diseases contribute significantly to the morbidity and
mortality of older Americans. Diseases such as arthritis,
asthma, chronic obstructive pulmonary disease (COPD) and other
respiratory conditions, cancers, diabetes, heart disease,
hypertension, osteoporosis, and stroke comprise the major
categories of chronic conditions affecting persons age 65 and
older. Cardiovascular diseases (CVD), primarily heart disease
and stroke, are the leading cause of death irrespective of
gender or racial origin. However, for women, cardiovascular
disease is responsible for more deaths than almost all of the
leading causes of death, including cancer. The general category
of cardiovascular diseases (CVD) includes not only heart
diseases such as coronary heart disease, but also hypertension
or high blood pressure and stroke. Until recently, death rates
for coronary heart disease had declined. However, with the
growing aged population, the slope of this decline has begun to
level off.
Another cardiovascular disease with a major impact on the
aged population is stroke. Stroke is the third leading cause of
death. Recent studies have identified disparities in treatment
for heart disease both by gender and race/ethnicity. There are
a growing number of racial and/ethnic groups in this country
who appear to be disproportionately sharing the burden of these
chronic diseases. Just as cardiovascular disease can result in
disabilities, arthritis and osteoporosis are also diseases that
cause disability and lost work days. As the population ages,
the impact of this disease may have major ramifications for
society as more and more persons become disabled. Osteoporosis
is a potential cause of disabilities because this disease
increases the risk of fracture. Data from the Medicare Current
Beneficiary Survey (MCBS) showed that the percentage of
Medicare beneficiaries reporting osteoporosis increased with
increasing age. The study also found that a higher percentage
of whites reported having had a hip fracture than nonwhites. A
final category of diseases are the respiratory diseases. Asthma
and COPD are among the 10 leading chronic conditions. It has
been found that deaths due to asthma are more likely to occur
in African Americans and Hispanics than among whites. In
summary, chronic diseases are quite prevalent in the aged
population. Little is known about the gender and racial
differences in patterns of utilization and health outcomes for
the Medicare population. Findings from this project will assist
HCFA in targeting policies, programmatic changes, education,
outreach, research and demonstration projects to achieve
improved health outcomes for our female Medicare beneficiaries.
Status: In progress.
Health status and Quality of Life for Women with Diabetes:
Data from the Medicare Current Beneficiary
Prj #:500-96-0516/13
Start Date: 09/30/2000
End Date: 09/29/2001
Funding: $92,490
Vehicle: Task Order
PI: Celia H. Dahlman [Fu Assoc's, Sub]
Awardee: CHD Research Associates, Inc.
PO: Marsha G. Davenport, M.D., M.P.H.
Description: This task order will develop a database,
create analytic files, and provide programming and analytic
support for studies on beneficiaries with diabetes from the
Medicare Current Beneficiary Survey (MCBS). These studies will
focus on gender and racial/ethnic differences for respondents
in the MCBS who reported having had a diagnosis of diabetes.
Chronic diseases contribute significantly to the morbidity and
mortality of older Americans. Diabetes is the seventh leading
cause of death in this country. However, the true burden of
diabetes is actually not known, because diabetes frequently
goes undiagnosed. The Centers for Disease Control and
Prevention (CDC) estimate that the number of persons with
undiagnosed diabetes to be over 5 million. At the present time,
it has been estimated that 10.3 million people have been
diagnosed with diabetes in the United States. HCFA's Women's
Health Workgroup developed an initiative on diabetes in
response to the Department's interest in proposals for the
Women's Living Long, Living Well and the Prevention
Initiatives. Diabetes was identified as a disease that affected
our beneficiaries across the life span and scope of all HCFA's
programs (Medicare, Medicaid, and the State Children's Health
Insurance Program). This project is designed to provide a
mechanism for on-going analyses from the Medicare Current
Beneficiary Survey (MCBS) and the Medicare administrative files
that are linked for these survey participants. Through creating
a database and analytic files, studies on Medicare
beneficiaries with diabetes can be conducted using several
years of data from the MCBS. Important issues related to
health, health status, co-morbid conditions, functional status,
disability, quality of life as well as costs and utilization of
health care services can be examined. We plan to study at a
minimum:
Demographic characteristics of beneficiaries who
report a diagnosis of diabetes (age; gender; race/
ethnicity; income; education; marital status; etc.)
Health and functional status (activities of daily
living; instrumental activities of daily living)
Health care services variables (usual source of care;
doctor and emergency room visits)
Co-morbid health conditions ( heart disease; stroke;
blindness; amputations; etc.)
Utilization of services from the link to the Medicare
administrative files for outpatient services; inpatient
hospitalizations; etc.
Use of preventive services appropriate for diabetics
(immunizations; eye exams; foot care; etc.)
Costs associated with preventive care and treatment
of Medicare beneficiaries with diabetes.
Changes in coverage policies for diabetic treatment
and care.
Status: In developmental phase.
Improving Quality in Long-term Care
Prj #:HCFA-99-0100
Start Date: 04/01/1999
End Date: 03/31/2001
Funding: $50,000
Vehicle: Purchase Order
PI: Janet Corrigan, Ph.D.
Awardee: National Academy of Sciences, Institute of
Medicine, Board on Health Care Services
PO: Sydney P. Galloway
Description: HCFA provided funds to support a portion of an
ongoing project in the National Academy of Sciences/Institute
of Medicine (IOM). Our funding would sponsor an additional
meeting of the project committee to further explore and
deliberate on its findings and recommendations related to the
definition and enforcement of regulatory standards, work-force
problems, organizational capacity for quality improvement, and
quality measurement/information strategies in long-term care
situations.
In 1986, IOM issued the report, Improving the Quality of
Care in Nursing Homes, which was to serve as a foundation for
the Nursing Home Reform Act of 1987. Since then, much has
changed including attitudes about those using long-term care,
ways of providing care, and strategies for assessing and
improving the quality of care. In 1997, with primary funding
from the Robert Wood Johnson Foundation, the IOM appointed an
expert committee to examine a broader range of long-term care
services, recipients, and quality improvement strategies than
those considered in the 1986 report. Questions being
investigated include:
What are the demographic, health, and other
characteristics of individuals requiring long-term care
and how are they changing?
What are the roles of the various long-term care
settings, and how do they relate to other components of
community care systems?
What are the strengths and limitations of existing
methods and tools to measure, oversee, and improve
quality of care and the outcomes of long-term care?
How can these methods and tools be improved?
What is known about the current quality of long-term
care in different settings and the extent to which care
has improved or deteriorated in the last 10-15 years?
What is known about the impact of long-term care
regulation, especially the Nursing Home Reform Act of
1987?
After working for over a year, the IOM committee concluded
that an additional meeting was needed given the complexity of
the topics being considered and a number of recent developments
in long-term care, including various initiatives by the
Department of Health and Human Services. In particular, the
committee directed that additional report text be drafted
related to payment issues and research directions. This HCFA
project provides the support to make this last portion of the
work possible.
Status: The final report is completed.
Direct and Indirect Effects of the Changes in Home Health
Policy and an Analysis of the Skill Mix of Medicare Home Health
Services Before and After the Balanced Budget Act of 1997
Prj #:HCFA-00-0108
Start Date: 03/16/2000
End Date: 03/23/2001
Funding: $24,298
Vehicle: Simplified Procurement
PI: Nelda McCall
Awardee: Laguna Research Associates
PO: Sydney P. Galloway
Description: This project provides partial support for a
project primarily funded by the Robert Wood Johnson Foundation
(RWJ). As part of this larger project, HCFA supplies needed
data and receives the results of a special study. The major
(RWJ) project examines three areas where impacts of the
Balanced Budget Act (BBA) might fall B the Medicare
beneficiary, home health care agencies, and the overall medical
and long-term care system. Analysis based on the data HCFA
supplies under this award, taken together, will help understand
the overall pattern of impacts and be useful in formation of
future reimbursement policy. The special study for HCFA looks
at beneficiary access. This will analyze pattern of Medicare
home health use before and after the implementation of the BBA.
There is a focus on assessing whether changes occurred in the
skill mix of types of visits received by home health users. It
will examine whether differential effects have occurred for
different categories of home health users and in different
geographic areas.
Status: The data have been accessed and the analysis are
being prepared.
Assessing Readiness of Medicare Beneficiaries to
Participate in Informed Health Care Choices
Prj #:17-C-90950/1
Start Date: 08/17/1998
End Date: 06/16/2000
Funding: $63,192
Vehicle: Cooperative Agreement
PI: James O. Prochaska, Ph.D.
Awardee: Pro-Change Behavior Systems
PO: Sherry A. Terrell, Ph.D.
Description: This study will adapt the investigator's
transtheoretical model of health behavior change using the
Medicare Current Beneficiary Survey (MCBS) data to predict a
Medicare beneficiary's readiness to make an informed decision
about his/her Medicare health insurance plan choice. The model
is a mathematical algorithm that assigns/classifies a case to a
stage of readiness to make a decision.
Status: The research team has received MCBS data for 1995-
1997 from HCFA and prepared related analytic files. Once 1998
MCBS files are available, the transtheoretical model can be
applied.
Analysis of Medicare Beneficiary Baseline Knowledge Data
Using MCBS
Prj #:500-95-0061/04
Start Date: 06/16/1999
End Date: 06/15/2002
Funding: $229,123
Vehicle: Task Order
PI: James M. Robinson, Ph.D.
Awardee: University of Wisconsin--Madison/Research Triangle
Institute
PO: Sherry A. Terrell, Ph.D.
Description:The purpose of this project is to analyze
Medicare beneficiary baseline knowledge data which have been
previously collected through the Medicare Current Beneficiary
Survey (MCBS). The program objective is to evaluate National
Medicare Education Program (NMEP) print material (Handbook:
1999 and Bulletin) and selected information distribution
channels (print, Internet, 1-800-MEDICARE). The policy
objective is to support HCFA strategic plan initiatives,
contribute to Government Performance and Results Act program
performance reporting, and provide feedback for monitoring and
continuous quality improvement of NMEP informational materials
directed to the Medicare population over time.
Status: The project is in the first of two phases. An
analysis plan has been approved for Phase I, MCBS data user
agreements executed, and MCBS Access to Care files for 1995-
1997 and associated supplemental files have been received.
Phase I data analyses have begun and several working measures
of knowledge constructed. A report entitled ``A Knowledge Index
Technical Note'' using Phase I data has been received and is
under review. Phase II will extend Phase I analyses using MCBS
1998 Access to Care files including special supplements--Round-
23 (beneficiary knowledge) and Round-24 (beneficiary needs).
Survey and Evaluation of New Medicare Members of
Medicare+Choice Plans
Prj #:500-95-0047/07
Start Date: 09/08/1999
End Date: 09/07/2001
Funding: $657,583
Vehicle: Task Order
PI: Merrile Sing, Ph.D.
Awardee: Mathematica Policy Research, Inc
PO: Peri Iz, Ph.D.
Description: The purpose of this project is to design a
survey for and collect data from Medicare beneficiaries who are
new members of Medicare+Choice (M+C) plans and to evaluate the
effectiveness of the National Medicare Education Program (NMEP)
for these beneficiaries. The objective is to understand the
special information needs of new Medicare members, their
sources of information (who/where), their preferred
distribution channels (how), their understanding of the basic
(standard) Medicare program, their understanding of their
particular M+C plan, and the impact NMEP activities may have on
new members' decision to choose an M+C plan or change their
plan. This project does not include the disenrollee population.
The project will support HCFA strategic plan initiatives,
contribute to Government Performance and Results Act program
performance reporting, and provide feedback for monitoring and
quality improvement to NMEP informational materials directed to
the M+C population over time.
Status: This project is in the start-up phase.
Evaluation of the Home & Community-based Services Waiver
Program
Prj #:500-96-0005/03
Start Date: 09/30/1998
End Date: 03/29/2002
Funding: $2,308,371
Vehicle: Task Order
PI: Lisa Maria Alecxih
Awardee: Lewin Group, The
PO: Renee Mentnech
Description: The Home and Community-Based Services (HCBS)
Waiver Program has been operating since 1981 and has
experienced tremendous growth in recent years. The percent of
Medicaid long-term care spending devoted to HCBS has increased
from 10 percent to 19 percent (between the financial and
beneficiary-level impacts of the program) in over a decade. The
aim of this task order is to gain a better understanding of the
broader HCBS waiver program and determine what programmatic
mechanisms have been successful.
Status: The project is ongoing.
Study of the Impact of Boren Amendment Repeal on Medicaid
Skilled Nursing Facilities
Prj #:Other/CF-1999-1
Start Date: 01/01/1999
End Date: 12/31/2000
Funding: $280,000
Vehicle: Grant
PI: Christine Bishop, Ph.D.
Awardee: Brandeis University, Heller Graduate School,
Institute for Health Policy
PO: Paul J. Boben, Ph.D.
Description:This project examines the impact of the repeal
of the Boren Amendment through a study of the relationship
between States' Medicaid payments to nursing homes and quality
and access to care for Medicaid recipients. The results of this
research will assist HCFA in preparing a report to Congress on
the effects of Boren Amendment repeal, as mandated by the
Balanced Budget Act of 1997. HCFA's participation in this
project is primarily to supply the needed data and to supervise
its use.
Status: The research team has just begun looking at data
from the Online Survey Certification and Reporting system and
Skilled Nursing Facility Cost Report data bases maintained by
HCFA. A report examining the relationship between State
Medicaid reimbursements for skilled nursing facilities and
access and quality of care for Medicaid eligibles is expected
soon.
Study of the Impact of Boren Amendment Repeal on Nursing
Facility Services for Medicaid Eligibles
Prj #:500-95-0060/03
Start Date: 09/29/2000
End Date: 10/10/2001
Funding: $268,875
Vehicle: Task Order
PI: Christine Bishop
Awardee: Brandeis University
PO: Paul J. Boben, Ph.D.
Description: The purpose of this project is to study of the
impact of repeal of the Boren Amendment on Medicaid eligibles=
access to Nursing Facility (NF) services and the quality of
care available to them in those facilities. The results of the
study will enable HCFA to submit the required Report to
Congress. The Balanced Budget Act of 1997 (BBA) effected the
repeal of a provision of Medicaid commonly known as the ABoren
Amendment. The Boren Amendment provided lower limits on the
amounts states could pay three types of institutional
providers: hospitals, nursing facilities and intermediate care
facilities for the mentally retarded (ICF/MR). State payments
had to be sufficient to cover the cost of Aefficiently and
economically operated facilities. The BBA also required HCFA to
study the effect of this repeal of the Boren Amendment on
access to care and quality of care provided to Medicaid
eligibles in these facility types. A Report to Congress must be
submitted by August 7, 2001. To partially fulfill this
statutory requirement, HCFA entered into a collaborative
arrangement with The Commonwealth Fund and Brandeis University
to study the relationship between state Medicaid reimbursement
policy and access to care and quality of care for Medicaid
eligibles in NFs. The Commonwealth Fund provided financial
support through a grant to Brandeis. HCFA's contribution has
been technical guidance and data, and in exchange was promised
a report that would have provided the basis for the Report to
Congress. The research plan of the Brandeis/Commonwealth
project relies on a number of strategies. First, survey data
collected under a HCFA contract by Wichita State University and
the University of California, San Francisco are used to track
changes in states NF reimbursement policies in the aftermath of
Boren Amendment repeal. Data from other sources--HCFA's OSCAR
and Medicare SNF cost reports databases--are used to construct
other variables that measure the relevant policy outcomes:
access to NF services and quality of care in those facilities.
Statistical methods are then used to determine what
relationships exist (if any) between the outcome variables and
state Medicaid reimbursement policy variables. Finally,
additional qualitative information on state responses to Boren
Amendment repeal is drawn from parallel research conducted by
an independent researcher also working under a Commonwealth
Fund grant and the Urban Institute through their Assessing the
New Federalism Project. Phase I of the project (November 1998
to December 2000) consists of a cross-sectional study of the
relationship between state payment policy and the relevant
outcome variables using data from 1996 (prior to Boren
Amendment repeal). Phase II (January through December 2001)
will expand the analysis to include data from 1999, allowing a
study of changes since the repeal of the Boren Amendment. In
November 1998, The Commonwealth Fund approved grant funding for
Phase I, and Brandeis University researchers began work shortly
thereafter. In January 1999 a Memorandum of Understanding was
signed formalizing the collaborative relationship between HCFA
and Brandeis University. On June 12, 2000, however, The
Commonwealth Fund informed HCFA that they would not provide
financial support for Phase II of the research. In order for
the Report to Congress can be submitted in a timely fashion
HCFA must now bring the research to completion.
Status: This project is underway.
Mauli Ola (Spirit of Life) Project
Prj #:18-C-91142/9
Start Date: 09/28/2000
End Date: 09/27/2005
Funding: $704,055
Vehicle: Cooperative Agreement
PI: Charman Akina
Awardee: Waimanalo Health Center
PO: Stephanie Monroe
Description: A significant number of Native Hawaiians do
not access medical services on a timely basis, even when such
services are made available and affordable. Of those who do,
their continues to be a significant rate of continued medical
non-compliance. This appears to be the case even where patients
demonstrate a basic understanding of the medical basis and
management strategy of their illness. Simple, straightforward
medical information and instruction are not, it seems,
sufficient as behavior motivators to effect long-standing
behavioral change in the Native Hawaiian population. It is this
underlying behavioral motivation that the Waimanalo Health
Center proposes to address in an integrated and comprehensive
outreach and preventive health demonstration project. The
Center proposes to significantly increase the number and
intensity of personal and culturally relevant motivators to
effect positive lifestyle changes. The Center would provide
culturally relevant and medically sound outreach, screening,
educational, and preventive health services for its entire
service area.
Status: This project is underway.
State of Minnesota ``Senior Health Options (MSHO) Project
Prj #:11-W-00024/5
Start Date: 04/01/1995
End Date: 12/01/2000
Funding: $0
Vehicle: Waiver-only Project
PI: Pamela Parker
Awardee: Minnesota, Department of Human Services
PO: Linda Frisch
Description: In April 1995, the State of Minnesota was
awarded Medicare and Medicaid waivers for a 5-year
demonstration designed to test delivery systems that integrate
long-term care and acute-care services for elderly dual
eligibles. The State targeted the elderly dually-entitled
population that resides in the seven-county metro area and St.
Louis county. Elderly Medicaid eligibles now required to enroll
in the State's current section 1115 Prepaid Medical Assistance
Program (PMAP) Demonstration are being given the option to
enroll in the Senior Health Options (SHO) Project, which in
essence adds long-term care and Medicare benefits to basic PMAP
benefits. Under this demonstration, the State is being treated
as a health plan that contracts with HCFA to provide services,
and provides those services through subcontracts with various
appropriate providers. The State is continuing its current
administration of the Medicaid-managed care program while
incorporating some Medicare requirements that apply directly to
the health plans with which the State would subcontract for
SHO. HCFA's direct oversight functions will continue to apply
to the overall demonstration and managing entity, which will be
the State.
Status: The State implemented the project in March 1997. It
is currently ongoing.
Multi-state Evaluation of Dual Eligibles Demonstrations
Prj #:500-96-0008/03
Start Date: 09/30/1997
End Date: 09/29/2002
Funding: $2,155,854
Vehicle: Task Order
PI: Robert L. Kane, M.D.
Awardee: University of Minnesota
PO: Noemi V. Rudolph
Description: This evaluation is designed to assess the
impact of dual eligible demonstrations in the States of
Minnesota, Colorado, Wisconsin and New York. Analyses will be
conducted for each State and across States. The quasi-
experimental design will utilize surveys, case studies, and
Medicare and Medicaid data for analysis. Major issues to be
examined include the use of a capitated payment strategy to
expand services while reducing/controlling costs, the use of
case management techniques and utilization management to
coordinate care and improve outcomes and the goal of responding
to consumer preferences while encouraging the use of
noninstitutional care. A universal theme to be developed is the
difference between managing and integration.
Status: Beneficiary surveys have been completed in the
Minnesota demonstration. Beneficiary surveys for the Wisconsin
demonstration are planned to be conducted in early 2000. Two
case study reports and the First Annual Report have been
submitted to HCFA. The New York demonstration received its
waivers in September 1999 and increased evaluation activities
will soon be underway.
Wisconsin Partnership Program
Prj #:11-W-00123/05
Start Date: 10/16/1998
End Date: 12/31/2004
Funding: $0
Vehicle: Waiver-only Project
PI: Steve Landkamer
Awardee: Wisconsin Division of Health and Family Services,
Department of Health and Family Services
PO: James Hawthorne
Description: The State submitted an application t in
February 1996 for Medicare and Medicaid demonstration waivers
to establish a ``Partnership'' model of care for dually-
entitled nursing home-certifiable beneficiaries who are either
under age 65 with physical disabilities or frail elders. This
project is utilizing Centers for Independent Living in Madison
and Eau Claire. This is believed to be the first site in the
nation offering fully capitated Medicare and Medicaid services
for people with physical disabilities. Waivers were approved on
October 16, 1998 and one site (Elder Care--Madison) became
operational on January 1, 1999. Community Care for the
Elderly--Milwaukee expected to become operational on March 1,
1999. Community Living Alliance--Madison and Community Health
Partnership--Eau Claire expected to become operational in the
spring of 1999. The ``Partnership'' model is similar to the
Program for All-inclusive Care for the Elderly (PACE) model in
the use of multidisciplinary care teams, prepaid capitation,
and sponsorship by community-based service providers. Rather
than the physician being co-located with the multi-disciplinary
team, the Partnership program will enable participants to use a
physician of their choice in the community who agrees to
participate as a contractor with the Partnership plan. This
model utilizes nurse practitioners and other multidisciplinary
team members to provide continuity and coordination with the
physicians who elect to participate. The Partnership also will
rely less on adult day care centers than do PACE sites as the
organizing focus for the provision of care. The model is
proposed as a fully voluntary enrollment model for 1,200
beneficiaries. All Medicare and Medicaid covered benefits are
offered under full capitation for eligible participants who
elect to enroll. Partnership sites for the frail elderly are
the existing PACE sites in Milwaukee and Madison. The
Partnership model for people with disabilities will utilize
Centers for Independent Living in Madison and Eau Claire. The
model for people with disabilities is believed to be the first
site in the nation for fully capitated Medicare and Medicaid
services for people with physical disabilities. Partnership
sites for the frail elderly are the existing PACE sites in
Milwaukee and Madison.
Status: The four sites became operational in early 1999 and
by the end of the year had a combined enrollment of over 700.
An evaluation of the Partnership, under separate contract,
began in mid-1999.
Continuing Care Network Demonstration, Technical Assistance
and Third Party Assessments
Prj #:18-C-91101/2
Start Date: 09/30/1999
End Date: 03/05/2005
Funding: $437,994
Vehicle: Cooperative Agreement
PI: Helena Temkin-Greener, PhD
Awardee: Community Coalition for Long Term Care
PO: Noemi V. Rudolph
Description: This initial award is part of a multi-year
technical assistance and third party assessment for the
Continuing Care Network (CCN) demonstration project in Monroe
County. Specific objectives include: (1) to analyze and compare
the proposed HCFA Medicare+Choice capitation methodology with
the CCN demonstration risk-adjusted payment model, (2) to
assure the collection of assessment data and administer a
subcontract with the independent assessor, (3) to design and
empirically test a Medicare and Medicaid risk/savings sharing
model, and (4) to examine CCN strategies for outreach/
education, marketing, and enrollment especially as it pertains
to the frail and dual eligibles. Data sources will include: the
Monroe County Medicare and Medicaid Database and the CCN
demonstration database, surveys, assessments conducted by the
independent assessor and by care plan nurses, interviews, and
focus groups.
Status: In progress.
Continuing Care Network Demonstration
Prj #:11-W-00126/2
Start Date: 09/30/1999
End Date:
Funding: $0
Vehicle: Waiver-only Project
PI: Linda Gowdy
Awardee: New York State Department of Health, Bureau of
Continuing Care Initiatives
PO: Noemi V. Rudolph
Description: Medicare waivers were approved for this
demonstration on September 1999. The CCN project, a 5-year
demonstration, is designed to test the efficiency and the
effectiveness of financing and delivery systems that integrate
primary, acute and long term care services under combined
Medicare and Medicaid capitation payments based on functional
status. The CCNs will enroll, over a five-year period, at least
10,000 Medicare-only and dually eligible beneficiaries who are
65 or older in Monroe County, New York. This population will
include those residing in nursing facilities, the nursing home
certifiable living in the community, and the unimpaired. This
is a voluntary program for both Medicare and dually eligible
beneficiaries. The approval is the first to combine the
authority under Section 402 of the Social Security Amendments
with the authority of Sections 1915(a) and 1915(c). The State
will amend the (Medicaid) State Plan to include a new class of
managed care organizations that will allow them to capitate
Medicaid service costs with home and community-based services
and to pay the CCNs one capitated payment for each Medicaid
enrollee. The State will also apply a parallel 1915(c) waiver
to support case management and invoke spousal impoverishment
protection for nursing home certifiable enrollees living in the
community. A limited chronic care benefit of up to $2,600 per
year (and not to exceed a $6,000 lifetime maximum) will be
available to all that join the CCN as community-based
unimpaired participants on enrollment. The DMS-1 assessment
instrument, which is normally employed to assess nursing home
certifiability in New York State, will be used to place
enrollees who are nursing home certifiable in the community
into one of the three rate cells based on level of impairment.
An independent third party assessor will conduct initial and
subsequent DMS-1 assessments, since the result of this
assessment will be used for both care planning and rate cell
determination.
Status: In progress.
Demonstration Project for Institutionalized Dually Eligible
Persons
Prj #:99-C-90869/3
Start Date: 04/30/1999
End Date: 06/30/2000
Funding: $59,538
Vehicle: Cooperative Agreement
PI: Martin Wasserman, MD
Awardee: Maryland Department of Health and Mental Hygiene
PO: James Hawthorne
Description: This Cooperative Agreement provides the
Maryland State Department of Health and Mental Hygiene (DHMH)
with funds to purchase technical assistance and to support
planning activities to develop two demonstration projects to
assist persons with physical disabilities who are under age 65
to move from nursing facilities to community-based settings.
The demonstrations would provide care coordination on a
capitated basis and would emphasize consumer choice and
direction. The demonstrations would depend on existing Medicare
Managed Care Organizations (MCOs) to enroll eligible
beneficiaries and to provide their medical care. The MCO's
would sub-contract with community based organizations, such as
Centers for Independent Living, to assist participants in
obtaining appropriate support services in the community and to
facilitate coordination of these services and the beneficiaries
medical care. DHMH has sub-contracted the developmental work
for this demonstration to the Center for Health Plan
Development and Management (CHPDM) at the University of
Maryland in Baltimore County.
Status: DHMH has subcontracted the developmental work for
this demonstration to the Center for Health Plan Development
and Management at the University of Maryland in Baltimore
County. The project has hired staff to coordinate planning
activities and has assembled a task force comprised of
consumers, providers, and representatives from DHMH to guide
the planning process. The project is on schedule for the
projected completion date of June 30, 2000.
Multi-state Dual Eligible Data Base and Analysis
Development
Prj #:500-95-0047/03
Start Date: 09/30/1997
End Date: 09/30/2001
Funding: $2,135,418
Vehicle: Task Order
PI: Don Lara
Awardee: Mathematica Policy Research, Inc.
PO: William D. Clark
Description: This project will use available Medicare/
Medicaid-linked statewide data in 10-12 States to develop a
uniform database that can be used by States and the Federal
Government to improve the efficiency and effectiveness of the
acute- and long-term-care services to persons eligible for both
Medicare and Medicaid (dual eligible). It will also conduct
analyses derived from these data to strengthen the ability to
develop risk-adjusted payment methods and deepen the
understanding of Medicare-Medicaid program interactions as they
relate to access, costs and quality of service. Finally, it
will recommend longer-range options that will improve the
usefulness of the database for operational and policy purposes.
Status: The project is constructing a multistate dual
eligible database and using these data for analyses.
Case Studies of Managed Care Arrangements for Dual Eligible
Beneficiaries
Prj #:500-95-0048/08
Start Date: 08/26/1999
End Date: 02/25/2001
Funding: $367,135
Vehicle: Task Order
PI: Edith Walsh
Awardee: Health Economics Research, Inc.
PO: William D. Clark
Description: The purpose of this project is to obtain
greater knowledge of the dynamics of Medicare and Medicaid
coordination of eligibility, benefits, and services at the
health plan level. It will provide preliminary identification
of issues that the Health Care Financing Administration,
States, health plan contractors and beneficiaries should
prioritize and address. It will identify exemplary and routine
approaches implemented by health plans for further
consideration and potential adoption by others. This project
examines health plans including their provider networks, care
management activities and beneficiary experiences. It will
identify exemplary and routine approaches implemented by health
plans for further consideration and potential adoption by
others. In 1997, an estimated 6.7 million Medicare
beneficiaries received some level of additional benefits
through Medicaid buy-in at some point during the year. These
dual eligible beneficiaries are estimated to represent 17
percent of all Medicare beneficiaries in 1997, and are
estimated to account for at least 28 percent of total Medicare
expenditures. For Medicaid, enrollment and expenditure
experience is strikingly similar. Dual eligible beneficiaries
are estimated to represent 19 percent of total enrollment and
35 percent of Medicaid expenditures, of which 57 percent is
Federal match to States. The growing importance of the dually
eligible population is magnified by the fact that the
population of Americans over 80+, those most likely to become
dually eligible due to frailty and impairment, is expected to
grow by 100 percent for men and 50 percent for women by the
year 2025. Beneficiaries dually entitled for Medicare and
Medicaid obtain health insurance coverage from these programs
in many combinations. They may be entirely in traditional fee-
for-service, Medicare+Choice risk contract plans with Medicaid
benefits in fee-for-service, Medicaid managed care arrangements
of varying definitions with Medicare fee-for-service, or in
combinations of Medicare and Medicaid contractual arrangements
within the same health plan organization. Some Federal
demonstration health plans more consciously attempt to
integrate Medicare and Medicaid financing at the plan level. It
is believed that, through improved contractual arrangements,
additional efficiencies in the organization and delivery of
services may lead to improved health plan performance. The
combined financing is intended to facilitate the integration of
medical care, hospitalization, and post-acute services with
community and/or residential supportive services and other
benefits, including prescription drugs. The availability of
this array of options varies considerably in health plans
across the United States. Even though total enrollment and
costs for services used by dual eligible beneficiaries in
Medicare and Medicaid represents a substantial figure, the
bifurcation of responsibility for this population results in a
consideration of dual eligibility as a subset of each program
subject to the statutory requirements of each. Rarely has a
lens been applied to program changes mandated in either program
that considers the impact of changes in one program and
resulting consequences on the other. The Balanced Budget Act
changes in Medicare home health payment and consequences for
State Medicaid illustrates this point. Similarly, research that
illuminates dual eligible issues often is focused on either
Medicare or Medicaid, but rarely both. There are many reasons
for this including data incompatibility, source of funding, and
primary purpose of the research. This task order is one of a
number of efforts intended to apply a lens to dual eligible
issues as the central point of focus. In this study the
dynamics of Medicare and Medicaid interactions at the health
plan level are to be investigated. Given the difficulty in
seeking to change both Medicare and Medicaid programs by
Statute or through demonstration and program waivers in order
to improve service delivery systems for dual eligible
beneficiaries, it is essential to develop a more complete
understanding of the way these programs interact at the
provider and beneficiary level. While it is important to
determine exemplary solutions to common problems that may have
potential for replication by others, it is equally important to
obtain a realistic portrait of the abilities and limitations of
health plans in working with the Medicare and Medicaid programs
to accomplish the facilitation, coordination, and integration
of health and supportive services for dual eligible
beneficiaries.
Status: The project is in the start-up phase.
Factors Associated with Low Mammography Rates among Elderly
Blacks
Prj #:20-P-90895/4
Start Date: 09/27/1998
End Date: 09/26/2000
Funding: $240,035
Vehicle: Grant
PI: Alma R. Jones
Awardee: Morehouse School of Medicine
PO: Richard Bragg
Description: The overall objective for the research is to
provide information that will ultimately lead to reductions in
breast cancer mortality among African American Medicare
beneficiaries, 65 years old and older in Fulton County and
DeKalb County, Georgia, by increasing the percentage of this
population that is screened for breast cancer annually. The
project will address the low mammography screening rates for
African American, nonhealth-maintenance-organization Medicare
beneficiaries in Fulton and DeKalb counties. The study will
develop, field test, evaluate, and disseminate a model for
identifying barriers to test breast cancer screening among
various populations. The proposed study will build upon
research previously performed by the breastcancer prevention
research group at Morehouse. In this instance, a trial to
increase the rate at which inner-city African American women of
various ages obtain breast and cervical cancer screening was
designed. Hence, the Principal Investigator wants to: Increase
the knowledge of breast cancer and improve the attitude toward
breast cancer screening. Increase the rate at which annual
screening mammograms are secured in the study population.
Status: This project, which was awarded under HCFA's grant
program for Historically Black Colleges and Universities, is in
progress.
Health Promotion in the African American Community: A
Computer-Based Nutrition Program
Prj #: 20-P-91120/6
Start Date: 09/25/2000
End Date: 09/24/2001
Funding: $120,754
Vehicle: Grant
PI: JoAnn Blake
Awardee: Prairie View A&M University
PO: Richard Bragg
Description: The purpose of the study is to investigate the
effectiveness of a computer-based nutrition education program
on the use of health promotion behaviors by African American
adults in community settings as compared to traditional methods
of instruction. An interactive multimedia computer program will
be used to teach nutrition to African American adults. A
research team of faculty and nursing students will implement
project activities. The investigators plan to validate the
feasibility of computer based intervention strategies and
materials that are designed to teach African American adults
about nutrition in a community setting when compared to
traditional methods of instruction. The project goals are: (1)
to form collaborative partnerships within minority communities
in need of health promotion focusing on nutrition, (2) to
examine the difference in outcomes of health education using a
computer based delivery method when compared to traditional
methods, and (3) to determine the feasibility of using a
computer-based education program to teach health promotion to
African American adults in urban community settings. A study
population of 200 individuals will be recruited from the
community. A two group pretest (Nutrition Survey and Health
Promotions Lifestyle Program (HPLP) behavior rating scale)--
posttest design will be used. The software program will present
information in a cultural relevant way that may be
individualized to the subject. A panel of experts will review
the program.
The experimental group will complete the pretest that
consists of a questionnaire on nutrition and the Health
Promotion Lifestyle Profile. The pretest instruments are
designed to determine baseline knowledge and use of health
promotion behaviors. After the baseline data is collected, the
experimental group will complete a multimedia interactive
computerized nutrition program developed by the investigators.
Instruction on nutrition in the areas of need identified by the
computer program will be provided. The control group will
complete the baseline data collection process, receive printed
information in the form of pamphlets and will be provided with
group instruction on nutrition. The researchers will be
available to assist with use of the computers and completion of
the data collection instruments. A body mass index will be
calculated for all participants and the posttest will be
administered 3 months and 6 months after the start of the
project. The applicant will develop and test the computer
program before using it with the experimental group.
Status: Study is in development phase.
Increasing Breast Cancer Screening in African American
Women: A Community Pilot Project
Prj #: 20-P-91123/4
Start Date: 09/25/2000
End Date: 09/24/2001
Funding: $124,990
Vehicle: Grant
PI: Margaret Hargreaves
Awardee: Meharry Medical College
PO: Richard Bragg
Description: The study seeks to determine the extent to
which breast cancer screening can be increased among low income
and elderly African-American women living in the Nashville area
(more specifically, around the East Nashville Family Health
Care Group Practice -ENC), using a combination of culturally
appropriate strategic approaches that are implemented through a
coordinated community effort. The main goal is to develop,
implement, and evaluate a culturally-sensitive multi-faceted
pilot program that seeks to improve breast cancer screening
knowledge (K), attitudes (A), and practices (P) in a high risk
population of poor and elderly African American women. The
specific objectives are: (1) to increase breast cancer
knowledge (K) in the targeted risk groups by 20 percent above
baseline; (2) to improve attitudes toward cancer screening (A)
by at least 1 standard deviation above baseline values; (3) to
increase the number of mammograms completed (P) among the
targets risk groups by 20 percent above baseline rates; and (4)
to improve the rate of early detection in the targeted risk
groups by 20 percent above baseline levels. This 2 year project
will involve a collaborative venture between Meharry's Cancer
Control Research Unit, the East Nashville Family Health Care
Group, the Community Coalition for Minority Health, the Middle
Tennessee Breast and Cervical Cancer Screening Coalition, and
other selected organizations and individuals in the East
Nashville Community who have an interest in breast cancer
prevention and control. The study has three phases: Phase 1:
Planning, 1-6 months; Phase 2: Implementation, 7-22 months; and
Phase 3: Evaluation, 9-24 months. Under Phase I four main
activities are proposed to be conducted: These activities are:
(1) Working with community organizations (becoming
knowledgeable with how the East Nashville community is
organized). (2) The development of an intervention program: (a)
cluster profiling methodology, (b) social marketing
methodology, and (c) stages of change methodology. (3) Training
health educators for the project. (4) Baseline data collection
KAP and barriers questionnaires administered. Random sample of
at least 100 women selected from cluster profiles around the
target area. Questionnaires will be administered by telephone.
Status: Project is underway.
Efficacy of a Culturally Sensitive Health Promotion Program
To Improve Exercise and Dietary Behaviors in African American
Elders with Hypertension
Prj #: 20-P-91130/7
Start Date: 09/25/2000
End Date: 09/24/2001
Funding: $98,838
Vehicle: Grant
PI: Lucille Davis
Awardee: Southern University and A&M College, School of
Nursing
PO: Richard Bragg
Description: The project is to test the efficacy of a
culturally sensitive health promotion program that seeks to
improve exercise and diet, two behaviors important in
controlling hypertension in African American elders with
hypertension. The project will compare the impact of outcomes
of; (1) knowledge, (2) efficacy expectations and outcomes
(beliefs about performing exercise and dietary behaviors), and
(3) stages of change on exercise and dietary behaviors of
elders who participate in one of two versions of a health
promotion program. One version would use a culturally sensitive
health promotion videotape (HPV) and the other, a culturally
sensitive health promotion self-care manual (HPM). These tools
have already been developed under a previously funded project.
The project will have a quasi-experimental design to test the
efficacy of using culturally sensitive videotapes and self care
manuals as part of a health education program to improve
hypertension knowledge, efficacy, stages of change, and
exercise behaviors in African American elders with
hypertension. The first year will be conducted in Baton Rouge,
LA and the second year in Jackson, MS, under the coordination
of the two participating universities. The intervention will be
conducted at public housing complexes and involve resident
coordinators who would serve as liaison between participants
and researchers. In Louisiana, the study population will be
drawn from 6 housing complexes involving approximately 700
units with a large proportion of older African Americans. In
Mississippi, 498 units including 152 units exclusively for the
elderly, and 346 units for multi-generational families will
comprise the target population. The sample size will consist of
150 African Americans, 50 individuals in each of the 3 groups.
Buildings will be randomized to one of the three groups.
Recruitment will involve meeting with staff and residents in
the designated buildings. Strategies to prevent attrition will
include weekly classes. Group one will use the videotape as
part of a lecture-discussion and skill building class. Elders
will also be given a copy of the videotape and instructions on
its use between classes. This group will be given a copy of the
manual and instructed on its use between classes. The control
group will not receive the intervention.
Provisions and incentives are incorporated into the design
to assure retention of subjects and to control for potential
intervention variability across sites. For example, a small
stipend will be paid for each interview. Inclusion criteria for
participating in the study are explicit and appropriate to the
goals and objectives of the study. Data will be collected at
baseline and remeasured at 3 and 6 months on 9 variables.
Status: Project is in development
A Population-Based Case Control Study of Ethnic Differences
in the Utilization of Elective Hip or Knee Replacement Surgery
for Arthritis
Prj #: 25-P-90948/6
Start Date: 09/30/1998
End Date: 09/29/2000
Funding: $250,000
Vehicle: Grant
PI: Agustin Escalante
Awardee: University of Texas Health Science Center at San
Antonio
PO: Richard Bragg
Description: This project examines the utilization of
elective hip or knee replacements for arthritis among Hispanics
and non-Hispanics in Bexar County, Texas. It directly assesses
persons hospitalized for these procedures between February 1999
and January 2000. The objectives of the project are to: Compare
ethnic background between persons hospitalized for elective
arthritis-related hip/knee replacement surgery and persons
hospitalized for other reasons. Examine the association between
socioeconomic status and acculturation and the likelihood of
recipients of hip/knee replacements being Hispanics compared to
others. Measure age-adjusted rates of elective replacement
surgery. Investigate to what extent Bexar County residents who
are Medicare and Medicaid beneficiaries undergo these elective
procedures outside the county. First, a case-control study will
be conducted comparing the ethnic background of recipients of
an elective arthritis-related hip or knee replacement surgery
against the ethnic background of age- and gender-matched
controls hospitalized for other reasons. Second, population-
based utilization rates will be developed for these elective
procedures using census-derived demographic information as the
denominator population. Finally, the completeness of these
estimates will be assessed using Medicare and Medicaid claims
data to measure the extent to which Bexar County residents
selected these elective procedures in hospitals outside their
county of residence.
Status: This project, which was awarded under the Hispanic
Health Services Research Grant Program, is in progress.
Cervical and Breast Cancer Screening for Post-Reproductive
Age Hispanic Women Residing Near the U.S.-Mexico Border
Prj #: 25-P-91062/9
Start Date: 09/20/1999
End Date: 09/19/2001
Funding: $263,281
Vehicle: Grant
PI: Francisco A.R. Garcia, MD, MPH
Awardee: University of Arizona, Arizona Board of Regents
PO: Richard Bragg
Description: The U.S.-Mexico border area in general and the
Arizona (U.S.)-Sonora (Mexico) border area in particular has
had a history of economic ties and the sharing of physical,
economic ties, cultural, and health characteristics. The
proposed study, which focuses on the border community of
Douglass/Sulphur Springs Valley in Arizona, highlights the
immense and unique health problems that plague the U.S.-Mexico
border region. Some of the main contributing factors associated
with the myriad of health problems in the region include:
poverty, unavailability, and accessibility of preventive health
and treatment services. Because there is a sparsity of research
in the area that addresses the health of the population, as
well as the dynamics associated with the etiology of prevalent
diseases, there may very well be an underestimation of the
incidence and prevalence of various diseases that seemingly
disproportionately afflict the population. Of particular
interest to the researchers is the preventive value of
screening for cervical and breast cancers associated with
Hispanic women who live in a border community (Douglass) on the
U.S.,-Mexico border. Reports suggest that breast and cervical
cancers may be two to three times higher for Mexican Americans
than for non-Hispanic whites.
The study proposes to address these problems by providing
information on : (1) the prevalence of breast and cervical
cancers, (b) barriers that affect access to and utilization of
health care, including screening services; and (c) successful
intervention strategies (involving health workers or
promotoras) that increase participation in and and sustained
involvement with breast and cervical cancer screening services.
To achieve this, the researchers propose to develop culturally
competent health promotion activities that will: (a) increase
rates of routines breast and cervical disease screening, (b)
promote disease prevention strategies, and (c) address the
significant cultural and structural barriers faced by these
women. This study will allow the researcher to address these
problems by using a 2-year community-based cohort intervention
study. Using data collected from a population-based cross-
sectional survey involving 600 women who will be interviewed,
the study seeks to gather information relating to utilization
and barriers to utilization of breast and cervical cancer
screening services. Following the completion of the interview,
the interviewer will assist the participant in scheduling a
clinic visit to have a variety of screening tests (e.g., pelvic
examination, including a pap smear; telecolposcopy; sampling
for HPV infection; and breast examination. Instruments or
questionnaires to be used in the study will be built from
previous or existing questionnaires associated with earlier and
ongoing projects that the PI and his research team are
associated with.
Status: In progress.
Understanding the Role of Culture in the Access and
Utilization of Telemedicine Health Services Among Hispanic,
Native Americans and White Non Hispanic Populations
Prj #: 25-P-91143/9
Start Date: 09/25/2000
End Date: 09/24/2001
Funding: $124,594
Vehicle: Grant
PI: Ana Maria Lopez
Awardee: University of Arizona Cancer Center
PO: Richard Bragg
Description: This project will provide a profile of
telemedicine service utilization by Mexican American, Navajo
and Non Hispanic white patients. The study focuses on the
health needs of rural Arizona residents, including some who
live near the U.S. border. These residents face geographic
barriers (distance) and supply barriers (lack of specialty
care) to access to care. These problems are compounded by
environmental hazard along the U.S. border and the lack of
economic opportunity in rural areas in Arizona. The applicant
provided a clear and compelling
Description: of these problems through the use of
statistics and multiple academic citations on health care in
Arizona. The objectives of the study are to: (1) identify if
telemedicine increases or decreases the number of clinic
encounters between patient and clinician at the same rate for
Mexican American, Navajo, and non-Hispanic White populations,
(2) examine if telemedicine alters the type or complexity of
the clinical encounter at the same level for these populations,
(3) assess if telemedicine affects the cost of providing
clinical services for the management of chronic and/or
rehabilitative conditions at the same amount for these
populations, (4) examine if telemedicine affects patient
compliance (e.g., taking medications as prescribed, doing
exercise as instructed, etc) at the same level for these
populations, (5) assess if minority patients perceive that
cultural competency is an important factor in the delivery of
telemedicine services such that it may impact utilization of
these services, and (6) examine how telemedicine impacts the
quality of life for these populations.
There are two goals that are offered for this study: (1) To
provide a profile of telemedicine service utilization, and (2)
to deepen and broaden the understanding of the role of culture
in access and utilization of telemedicine health services.
These goals will be achieved via the development and
implementation of a patient satisfaction survey, a provider
survey, and chart review. The project has access to a cohort of
200 patients stratified by location. This research is tracking
individuals within an existing service project. The enrollment
is constrained by the scope of current services. It is
estimated that 50 participants will be studied at each of the
four sites for a total of 200 individuals. The ethnic
distributions are assumed to be as follows: the population of
Springerville is 100 percent non Hispanic white, the populaton
of Ganado is essentially 100 percent Navajo, and the
populations of Douglass and Nogales are approximately 80
percent Mexican-American and 20 percent non Hispanic white.
These population distributions result in an expectation for
enrollment Mexican-Americans, 70 non Hispanic whites, and 50
Navajo. The first three objectives will be evaluated from
direct patient chart review and assessment of the discharge and
billing code data. The compliance objective will be assessed
using a simple survey technique. The final two objectives will
be assessed via patient surveys. These surveys are based on an
existing self-administered questionnaire that serves to measure
patient satisfaction with telemedicine services in terms of
quality of care.
Status: Project is in development phase.
A Systematic Approach to Improving Pap Smear Screening
Rates Among
Prj #: 25-P-91150/9
Start Date: 09/25/2000
End Date: 09/24/2001
Funding: $124,450
Vehicle: Grant
PI: Helda L. Pinzon-Perez/Vera Kennedy
Awardee: California State University, Fresno Foundation,
College of Health and Human Services, Grants and Research
PO: Richard Bragg
Description: This project will identify barriers to Pap
smear screening facing Hispanic/Latino women within a Medicaid
managed care system. The American Cancer Society (ACS) criteria
for Pap smear screening will be used: testing with the onset of
sexual activity and repeat pap smears every 1-3 years at the
physician's discretion. Hispanic/Latina populations are the
ethnic groups with the highest incidence of cervical cancer,
and it is increasing. Cervical cancer rates in the San Joaquin
Valley are 10.6 new cases and 3.3 deaths per 100,000 women,
i.e., 10 percent and 50 percent higher, respectively, than the
state as a whole. A major reason for these high rates is under-
utilization of Pap smear screening. The goals of this project
are: to identify the alterable barriers to Pap smear screening
facing Hispanic/Latino women within a Medicaid managed care
system; to measure the proportion of Latina women within a
Medicaid managed care system who are screened for cervical
cancer; and to design a comprehensive community-based outreach
and health education intervention strategy to improve the
cervical cancer screening rates among the Hispanic/Latina
population. The results from this study will be used in the
training of medical residents at the University of California
San Francisco in Fresno and it will be shared and disseminated
to other health care providers, which will enhance the ability
of service providers to provide culturally competent training
and services as well. The study will focus on the major aspects
of care affecting Pap smear screening. The participants will be
recruited from 4 large community health centers (urban vs.
rural) that serve predominately Hispanics in the Central Valley
and the Blue Cross Managed MediCaid system. The study design
involves structured interviews (covering the above aspects of
care) with a random sample of 300 with 100 from each of three
groups of women: (1) seen by a physician + Pap smear within 3
years, (2) seen by a physician + No Pap smear within 3 years,
and (3) Not seen by a physician + No Pap smear within 3 years.
A pilot study will be done with 30 women. A comprehensive
community-based outreach and health education intervention
strategy and prevention program will be compared (involving
strategies such as call and recall system with incentives,
``Consejeras'' community health workers, mailed reminders,
discussion groups in native language, use of female providers
and interpreters, provision of transportation, etc.) to improve
pap screening rates among the target group of Hispanic women.
Status: Project is in develpment phase.
MassHealth: Senior Care Options Medicare Enrollment Broker
Prj #: 500-00-0038
Start Date: 09/28/2000
End Date: 09/28/2001
Funding: $170,289
Vehicle: Contract
PI: Marion E. Reitz
Awardee: Maximus, Inc.
PO: William D. Clark
Description: This project involves demonstration-specific
design development in Phase I. If awarded Phase II, the project
will provide operational support for features being implemented
in the MassHealth: Senior Care Options research/demonstration
initiative sponsored by the Health Care Financing
Administration (HCFA) and the Massachusetts Division of Medical
Assistance (DMA). The Phase I consists of a developmental
design phase culminating in the preparation of an Enrollment
Broker Operations Protocol and the performance of operational
system pilot tests. Phase II will implement the operational
support activities. A decision to award
Phase II is to be based on the feasibility of the proposed
enrollment broker operational activities as described in the
Enrollment Broker Protocol and the readiness of the contractor
to perform such activities. Award of
Phase II also is to be determined by the separate approval
by HCFA and DMA of MassHealth: Senior Care.
Status: Project is in development phase.
Readmission and Access
Prj #: 30-P-91022/7
Start Date: 01/10/1999
End Date: 01/09/2000
Funding: $21,600
Vehicle: Grant
PI: Cindy Hornberger
Awardee: University of Kansas Medical Center
PO: Carl Hackerman
Description: The primary aim of this study is to determine
the relationship between access to health services and heart
failure outcomes among Kansans aged 65 years and older who were
discharged with DRG 127 during 1995. Heart failure is the only
major cardiovascular disorder that is increasing in incidence
and prevalence as the population ages. Heart failure is the
most common diagnosis related grouping billed to Medicare. A
significant portion of these costs are due to repeated
readmissions. Readmission rates for heart failure within the
first 14 days to 1-year range from 12.5 to 47.5 percent.
Readmission frequency and mortality are related to access,
which includes (a) availability of services, such as distance
to health care services, (b) individual and community social
determinants of well being, such as income and educational
levels, and (c) actual utilization of health services. The
project will use Individual-level and ecological-level analyses
to examine the relationships between the dependent variables of
readmission rate and mortality, and the independent access
variables using merged data sets. The access variables will
include the availability of emergency and/or community
hospitals. emergency transportation, specialty and/or primary
care providers; the number of home health care visits; and
county-level social determinants. The Medicare data come from
the Kansas and Missouri peer review organizations. Other data
sources include the Area Resource File; Kansas Kids Coalition,
Inc.; the Kansas Hospital Association; and the Kansas Health
Institute. Validity concerns regarding readmission rates, as an
unbiased indicator of disease severity will be addressed.
Statistical methods will include descriptive statistics,
correlational studies, analyses of variance, and linear
regression techniques.
Status: In progress.
Home Care Services: The Effect of Unmet Need on Health Care
Utilization
Prj #: 30-P-91010/9
Start Date: 01/10/1999
End Date: 01/09/2000
Funding: $21,600
Vehicle: Grant
PI: Lisa G. Matras-Schmidt
Awardee: University of California, Department of Health
Services
PO: Carl Hackerman
Description: The main objective of this study is to examine
how the need for home care services and the service delivery
mechanism itself affect the use of health care services among a
population of Medicare-eligible elderly and disabled persons
receiving home care. Home care is one of the fastest growing
components of personal health expenditures. However, among
persons receiving home care, there is still a considerable
amount of unmet need--either a lack of, or insufficient help
with, activities of daily living and instrumental activities of
daily living. Moreover, different models of service delivery
have been developed to provide home care. Both of these
factors, unmet need and service delivery mechanism, can have
significant impacts on costs of home care, as well as quality
of life for home care recipients. However, the effect of these
factors on the utilization of health services has not been
included in past studies of home care programs. This research
addresses the following: (1) Do persons with more unmet home
care personal assistance needs utilize more health services
than those with fewer unmet personal assistance needs and (2)
Does the service delivery method of home care (client self-
directed versus home care agency model) affect health care
utilization? Data come from two sources which will be linked
together, (1) a survey of individuals receiving home care
services through the California In-Home Supportive Services
program and (2) Medicare claims data. Multiple regression
analysis will be utilized to examine the effects of service
delivery mechanism and unmet personal assistance needs on use
of health services. In addition, a stratified analysis based on
level of disability will be done in order to determine if the
effects vary by degree of disability.
Status: In progress.
Customer Utilization of Prescription Drugs
Prj #: 30-P-91007/5
Start Date: 01/10/1999
End Date: 01/09/2000
Funding: $19,171
Vehicle: Grant
PI: Julie M. Ganther
Awardee: University of Wisconsin--Madison, School of
Pharmacy
PO: Carl Hackerman
Description: The main objectives oft this study are to: (1)
examine the effect of insurance on prescription drug
utilization, (2) examine the effect of medical care preferences
on prescription drug utilization, and (3) explore the
interaction between medical care preferences and insurance
coverage. The expansion of insurance coverage for prescription
drugs may be one factor in the large growth in prescription
drug expenditures over the past two decades. However, consumer
preferences for treating health problems also may effect
prescription drug utilization. Some consumers prefer to see a
doctor and/or take a prescription drug almost any time they
have a health problem while other consumers prefer to self-
treat most health problems. In addition to directly affecting
prescription drug utilization, these preferences may influence
the effect of insurance coverage on prescription drug
utilization. For example, it is unlikely that consumers who
prefer to avoid using prescription drugs would increase their
utilization dramatically just because they had insurance
coverage. Data will be collected via mail survey from a random
sample of Wisconsin consumers age 50 and over. A two-part
econometric model will be used to examine whether health
insurance coverage and medical care preferences effect the
number of prescriptions and the cost of prescriptions used in a
30 day reference period. Medical care preferences will be
measured using a 10--item scale. In order to account for
possible selection bias in insurance choice, consumers will be
asked to report the source of their prescription drug
insurance. The analysis will be done separately for the
respondents who received their insurance from a large employer.
These insurance coefficients will be compared to the insurance
coefficients for the entire sample to determine the magnitude
of the selection bias.
Status: In progress.
Factors of and Variations in Hospitalization Rates among
Elderly Nursing Home Residents: Searching for Indicators of
Appropriate Levels of Acute Care
Prj #: 30-P-91009/1
Start Date: 01/10/1999
End Date: 01/09/2000
Funding: $21,561
Vehicle: Grant
PI: Mary Ellen Whelan
Awardee: University of Massachusetts-Boston
PO: Carl Hackerman
Description: This project aims to further the understanding
of the interface between nursing homes and hospitals. It will
closely examine one aspect of this care continuum,
hospitalization among nursing home residents. The project
involves an empirical investigation of the relative explanatory
contribution of individual patient risk factors, facility-level
structural factors and area market health delivery factors in
explaining variations in hospital utilization rates among
dually-eligible, nursing home residents in the state of
Massachusetts. Using longitudinal data, all hospitalizations
will be analyzed via multivariate regression techniques to help
disentangle the influence of practice style differences from
medical needs among nursing homes and to determine whether
variations in transfer rates are associated with high (low)
discretionary and/or certain ambulatory care sensitive
conditions. In an attempt to curb burgeoning Medicaid
expenditures associated with nursing home care, various state
Medicaid cost containment strategies for nursing homes have
been implemented. By and large, the payment policies enacted
reflect prospective rate setting methodologies, meaning that
Medicaid reimbursement to nursing homes is based on a capitated
system, often with case-mix adjustment allowances, rather than
an individual based or flat-rate cost strategy. Although
research suggests that these changes in Medicaid reimbursement
polices succeeded in improving access to nursing homes for
certain heavy-care residents, policy concerns remain regarding
the overall effects of these payment systems on health care
accessibility.
Status: In progress.
Effect of Competition on Quality of Medicare
Prj #: 30-P-91016/5
Start Date: 01/10/1999
End Date: 01/09/2000
Funding: $21,596
Vehicle: Grant
PI: Tiffany Radcliff
Awardee: University of Minnesota
PO: Carl Hackerman
Description: This research examines the relationship
between market structure and quality of care using data that
defines quality with conformity to accepted clinical practice
guidelines. This project explores the role of competition in
the provision of appropriate care once patients are admitted to
hospitals with acute myocardial infarction.
Price regulation within the U.S. health system is
increasing. For example, during the 1980s the Health Care
Financing Administration implemented the Prospective Payment
System with predetermined and fixed hospital payment rates
based on diagnosis codes. Movement from cost-based payment to
external price regulation for health services has consequences.
What happens to quality of care across different types of
competitive environments when the price of health services is
fixed by external regulation? Descriptive statistics and
multivariate regression are used to test the following research
hypotheses: 1. Under price regulation, quality of care will
increase with the level of market competition. 2. Other
factors, including whether the market is rural, will affect
quality of care. Quality of care for urban residents will be
higher than for rural residents. In this work the sample
includes the majority of Medicare patients hospitalized with
acute myocardial infarction during 1994-95. The quality
indicators were abstracted from inpatient medical charts by
Peer Review Organizations as part of the Health Care Financing
Administration's Cooperative Cardiovascular Project.
Competition will be measured using various definitions of
market areas and measures of market competition.
Status: In progress.
Post Acute Care Use and Early Hospital Readmission of
Hospitalized Elderly Medicare Patients
Prj #: 30-P-91018/5
Start Date: 01/10/1999
End Date: 01/09/2000
Funding: $21,596
Vehicle: Grant
PI: Wen-Chieh Lin
Awardee: University of Minnesota
PO: Carl Hackerman
Description: The objective of this project is to
investigate the variation in hospital discharge location and
subsequent early hospital readmission attributable to patient,
hospital, and market area characteristics for elderly Medicare
patients. The Balanced Budget Act of 1997 (BBA) expanded the
prospective payment system to post-acute care. The BBA also
expanded the definition of transfer cases by treating discharge
to post-acute care as hospital transfers (for selected
Diagnostic Reimbursement Groups.) These expansions are likely
to result in new patterns of post-acute care choice and
utilization. Understanding the attributable variations of will
provide information for reforming post-acute care services and
policy options for bundling post-acute care payments in the
future. The specific aims for this study are: (1) investigate
patient, hospital, and market factors affecting hospital
discharge location (a two-level (patient and hospital)
hierarchical model will be established to investigate the
variation in the probability of receiving a specific type of
post-acute care for patients (a) within hospital-market and
then (b) across hospital-market. The hospital and market area
(county) characteristics are attached to the hospital.) (2) To
investigate quality of care using early hospital readmission as
the indicator (the similar structure of the two-level
hierarchical model will be used to investigate this issue by
including the post-acute care choice in the model.)
Status: In progress.
Improving Health Outcomes Using New Psychosocial Screens
Prj #: 30-P-91025/2
Start Date: 01/10/1999
End Date: 01/09/2000
Funding: $21,595
Vehicle: Grant
PI: Deborah N. Peikes
Awardee: Princeton University
PO: Carl Hackerman
Description: This study addresses a central challenge faced
by the Medicare program, to control costs by reducing the
demand for health services. This study characterizes critical
sociodemographic, psychological, and social factors, which
place people at risk for later illness so that appropriate
interventions can be made to reduce those risks. It will
identify key protective factors that contribute to the
maintenance of long term health -information critical to
increasing the number of disability-free years enjoyed by the
population. The project uses the Wisconsin Longitudinal Survey
(WLS), an extensive set of longitudinal data collected on
roughly 10,000 Wisconsin high school graduates born in 1939.
This cohort precedes the bulk of the baby boom generation by
about a decade. The ``boomers'' are expected to tax the
Medicare system in the coming years.
Hence lessons gained from this sample can be used to target
preventive efforts to reduce the amount of ill health faced by
the younger baby boomers, and, in the process. lower Medicare
expenditures. The project will isolate constellations of
factors in the Wisconsin respondents' life histories, which
predict health outcomes in later life. To do so, it will
construct life histories which incorporate extensive survey
information about adversity and advantage across multiple
domains, occurring throughout life (e.g., early background and
starting resources, educational and occupational attainment,
job conditions, marriage and parenting, social support and
participation in voluntary organizations). The integration of
these multiple domains, organized around the person as the unit
of analysis, constitutes a novel approach to explicating later
life health status. It will then apply Boolean-logic analytic
methodology to isolate key factors affecting health outcomes
and utilization patterns.
Status: In progress.
Economic Impact of Outpatient Prescription Drug coverage on
Total and Specific Health Expenditures and Service Use of
Medicare Beneficiaries
Prj #: 30-P-91017/5
Start Date: 01/10/1999
End Date: 01/09/2000
Funding: $21,579
Vehicle: Grant
PI: Margaret Artz
Awardee: University of Minnesota
PO: Carl Hackerman
Description: This research investigates the economic impact
of outpatient prescription drug coverage for Medicare
beneficiaries in terms of health care expenditure and service
use. Prescription medications play a significant role in the
health care regimens of the elderly and represent a significant
portion of their out-of-pocket health care expenses. Medicare
does not cover outpatient prescription drugs, yet little more
than half of Medicare beneficiaries who purchase a supplemental
insurance policy choose one with a prescription drug benefit.
Specifically, this research will determine if those elderly
possessing Medicare supplemental insurance with prescription
coverage have lower total and specific health care expenditures
and/or specific health care use compared to elderly
possessing either Medicare supplemental insurance without
preseciption coverage or Medicare alone. Estimation of per
capita differences in annual expenditures and service use will
also be calculated. Generosity of the outpatient prescription
drug coverage in terms of cost sharing is figured to play an
important role in the expenditures spent and/or service used by
the elderly.
Status: In progress.
Nursing Home Quality of Care: Time, Competition and Demand
Prj #: 30-P-30238/4
Start Date: 01/03/2000
End Date: 01/02/2001
Funding: $30,669
Vehicle: Grant
PI: Virender Kumar
Awardee: University of North Carolina at Chapel Hill,
Office of Research Services, for Department of Health Policy
and Administration
PO: Carl Hackerman
Description: The project assesses how competition and its
influence on the chronic health care market, and the OBRA 87
regulations affect the quality of nursing home care. Variation
in competition over a twelve year time period and variation
across the country will be used to identify how competition
affects quality. Measures of quality will be health outcomes of
individuals assessed through claims data. Three waves of the
National Long-Term Care Survey will be used as a basis to
identify individuals admitted to a nursing home for the study
sample. The analysis will use simultaneous equation methods to
derive consistent estimates of the Medicaid reimbursement rate,
competition, and OBRA 87 effects on quality and accessibility
of nursing home care. In this time of concerns about limited
funds and the quality of nursing home care and accessibility to
care for Medicaid beneficiaries, the topic is of great
interest.
Status: In progress.
Access to Medicare Home Health Care in the Wake of the
Balanced Budget Act
Prj #: 30-P-30245/3
Start Date: 01/03/2000
End Date: 01/02/2001
Funding: $32,390
Vehicle: Grant
PI: Joan F Davitt
Awardee: Bryn Mawr College, Graduate School of Social Work
and Social Research
PO: Carl Hackerman
Description: Recent changes to the Medicare home health
benefit have altered the way that home health care agencies
will be reimbursed. It has been estimated that the new
reimbursement system, referred to as the Interim Payment
System, will reduce agency revenues by 15-22 percent. Such
reductions may encourage agencies to alter the amount, duration
or type of benefits provided to certain types of home health
care patients. This study will investigate whether certain
types of patients are experiencing reductions in access to care
or in service receipt including: (1) not being admitted to home
health services; (2) being discharged early; (3) receiving less
services; or (4) receiving less expensive services. This study
consists of a secondary analysis of data from the Medicare
Current Beneficiary Survey (MCBS) Access to Care, Public Use
File and HCFA claims files for the years 1996 and 1998. These
will comprise the primary data sources for this study. The
researcher will also obtain the Provider of Services Extract
File from the OSCAR data base. The researcher will also conduct
qualitative interviews with home health agency staff in an
attempt to enhance the depth of understanding of these issues.
Statistical analyses will allow the researcher to:
determine whether this particular policy change is affecting
access to care; to test hypotheses regarding utilization
patterns; to understand which factors (such as patient
characteristics, agency characteristics, and supply-side
factors) are more predictive of specific utilization patterns;
and to understand the explanatory power of sets of independent
variables. Qualitative interview data will allow the researcher
to understand agency practices post-IPS, providing greater
sensitivity to contextual elements and provider perspectives.
These interviews will also be used to check for validity in the
interpretation of quantitative data and to identify provider
practices that may not be reflected in the claims files.
Information from this study will be shared with policy makers
and home health agency providers and may be utilized to improve
the design of the prospective payment system or to design
necessary clinical criteria for reimbursement limit exemptions
in home health care.
Status: In progress.
Outcomes and Reimbursement of Stroke and Hip Fracture
Rehabilitation
Prj #: 30-P-30247/2
Start Date: 01/03/2000
End Date: 01/02/2001
Funding: $32,400
Vehicle: Grant
PI: Anne Deutsch
Awardee: State University of New York at Buffalo, Sponsored
Programs Administration, for School of Nursing
PO: Carl Hackerman
Description: Inpatient rehabilitation services for Medicare
beneficiaries may be delivered in either rehabilitation
hospitals/units or in skilled nursing facilities (SNF) and the
distinctions between services provided in these 2 settings has
narrowed in recent years. Given the differences in costs, it is
of interest to compare functional outcomes of beneficiaries who
have received rehabilitation services in comprehensive versus
SNF-based settings after experiencing a hip fracture or stroke.
The study sample will include Medicare beneficiaries who
recently experienced a hip fracture or a stroke and were
discharged from either a rehabilitation hospital/unit or a SNF
that subscribed to the Uniform Data System for Medical
Rehabilitation. This data system includes both admission and
discharge measurements of functional status. The study will
compare ability to perform motor functions, Medicare
reimbursement data, rehabilitation length of stay; and total
length of stay between beneficiaries in the 2 settings while
adjusting for admission functional ability, age, co-morbid
conditions, and a number of other demographic, diagnosis-
related, and health system related variables.
Status: In progress.
Healthy Aging Project
Prj #: 500-98-0281
Period: 10/30/1998-9/29/03
Funding: $3.7 million
Award: Cost reimbursement contract
PI: Larry Rubenstein, M.D.
Awardee: RAND, 1700 Main Street, Santa Monica, CA 90401
PO: Pauline Lapin, Office of Clinical Standards and Quality
Description: A key challenge to the health care system will
be to determine how to prevent or slow the progression of
disability in the senior population. There will be a total of
76 million seniors living in the United States in 2030--a
dramatic increase from the 35 million today. This population
surge will substantially increase the demand for health care by
older people, who experience much higher rates of morbidity and
mortality than younger people. The Health Care Financing
Administration (HCFA) developed the Healthy Aging Project to
identify, test and disseminate evidence-based approaches to
promote health and prevent functional decline in older adults.
HCFA awarded RAND a five-year contract to produce reports
synthesizing the evidence on how to improve the delivery of
Medicare clinical preventive and screening benefits. RAND is
also exploring how behavioral risk factor reduction
interventions, such as smoking cessation, might be incorporated
into Medicare.
The first evidence report, Interventions that Increase the
Utilization of Medicare-funded Preventive Services for Persons
Aged 65 and Older, is an important guide for providers and
health care systems seeking to improve the use of influenza
immunizations, pneumococcal vaccinations, mammography, Pap
tests and colon cancer screening. A key finding from this
report is that organizational changes are effective in
improving the delivery of preventive services. Standing orders
are a type of organizational change that allow appropriate non-
physician staff to offer services, usually vaccinations,
without an individual physician prescription. HCFA and the
Centers for Disease Control and Prevention (CDC) are
collaborating on a demonstration project to implement standing
orders to increase influenza immunization rates in all of the
nursing homes located in nine states. Medicare's quality
improvement contractors, the peer review organizations or PROs,
are working on this initiative.
Another demonstration being conducted under the Healthy
Aging Project tests the feasibility of implementing a smoking
cessation benefit in Medicare. Three benefit options, including
telephone counseling, are being compared to assess their
effectiveness in promoting smoking cessation. HCFA commissioned
an evidence report on smoking cessation, and this demonstration
is based on that report and the U.S. Public Health Service
clinical practice guideline on smoking cessation.
HCFA is interested in comprehensive and systematic
approaches to health promotion, which address both clinical
prevention and behavioral risk factor reduction. Health risk
appraisals with tailored feedback and follow-up are a promising
tool for doing just that. HCFA has commissioned an evidence
report on health risk appraisals, as well as chronic disease
self-management, physical activity and falls prevention. RAND
is synthesizing the evidence on these strategies and addressing
the Medicare program and policy implications involved in
testing them in Medicare demonstrations in its reports.
HCFA coordinated the development of the Healthy Aging
Project with the Agency for Healthcare Research and Quality
(AHRQ). This project was designed to complement other
Departmental initiatives, such as Healthy People 2010, and the
U.S. Preventive Services Task Force. HCFA is conducting the
Healthy Aging Project in collaboration with the AHRQ, the CDC,
the Administration on Aging, and the National Institutes of
Health.
Status: Two evidence reports are currently available--
Interventions that Increase the Utilization of Medicare-funded
Preventive Services for Persons Aged 65 and Older and
Interventions to Promote Smoking Cessation in the Medicare
Population. A pilot project testing the implementation of
standing order interventions in nursing homes is being
conducted in nine states. A demonstration to test the
feasibility of implementing a Medicare benefit for smoking
cessation will be conducted in seven states. Final revisions
are being made to the evidence report on health risk appraisals
and targeted interventions; this report should be available in
the next few months. Reports on chronic disease self-
management, physical activity and falls prevention are
currently in various stages of the evidence review process.
NATIONAL INSTITUTES OF HEALTH
Older Americans are generally better off healthier and
wealthier than ever before.\1\ A combination of factors,
including the translation of critical research advances into
prevention and treatment strategies and the advent of health
and social welfare programs, have dramatically improved the
quality of life for older people. Average life expectancy in
the United States has at least doubled over the past century,
from an average of 49 years in 1900 to age 76 at the turn of
the century. The rate of disability among people age 85 and
older substantially declined from the 1980s through the mid-
1990s, and currently a majority of people age 65 and older rate
their health as good or excellent. Programs such as Social
Security and Medicare have improved the fiscal well-being of
older people in the United States, enabling many individuals to
enjoy a healthy and active retirement.
---------------------------------------------------------------------------
\1\ Federal Interagency Forum on Aging Related Statistics. Older
Americans 2000: Key Indicators of Well Being 2000.
---------------------------------------------------------------------------
Although the news is promising, good health is far from a
universal reality for older Americans. The latest national
surveys indicate that about one-fifth of people age 65 and
older, more than 7 million people, report some disability.
Chronic disease, memory impairment, and depressive symptoms
affect large numbers of older people and the risk of such
problems significantly rises with age. Nearly half of those age
85 and older suffer from Alzheimer's disease.\2\ These millions
of less fortunate older people struggle with daily activities
as simple as bathing and dressing, with families and friends
taking on the difficult and often costly role of caregiver. The
outlook for aging minority groups is particularly troublesome
given the obvious health disparities that research has shown
exists between older white Americans and their minority
counterparts.
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\2\ Evans, DA, Funkenstein HH, Albert MS, et al. Prevalence of
Alzheimer's disease in a community population of older persons; higher
than previously reported. JAMA 262: 2551-2556, 1989.
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An increasing interest in aging research is driven in part
by a projected dramatic increase in the older population.
According to the United States Census Bureau, by 2030 the
population of people 65 years and older will double. The over-
85 group, often referred to as the ``oldest old,'' is the
fastest growing segment of the older population and is
projected to comprise 20 million people by the middle of this
century. The implications of this dramatic increase in the
aging population are numerous and research has an important
role to play in providing solutions to the challenging issues
posed by an aging society.
Understanding the difference between advanced years that
are active and independent and those that are characterized by
frailty and dependence is at the heart of research supported by
the National Institute on Aging (NIA), a component of the
National Institutes of Health (NIH). The NIH is the principal
biomedical research arm of the Federal government. The NIA,
which was established by Congress in 1974, sponsors biomedical
and behavioral research on the aging process and diseases and
conditions affecting the elderly. NIA also leads the Federal
research effort on Alzheimer's disease. Through independent, as
well as collaborative, research efforts, the NIA and the other
Institutes and Centers that comprise the NIH are working to
reduce disability and disease and promote healthy lifestyles
for older people.
This report highlights a number of significant aging-
related research advances and activities supported or conducted
by the NIH in 1999 and 2000. Section I of this report outlines
key advances reported by the NIA for 1999 and 2000 in four
major areas of research. Section II provides selected findings
from some of the other NIH institutes involved in aging
research. They are: National Institute on Mental Health (NIMH);
National Eye Institute (NEI); Office of Research on Women's
Health (ORWH); National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK); National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS); National Center for
Complementary and Alternative Medicine (NCCAM); National
Institute on Deafness and Other Communication Disorders
(NIDCD); National Heart, Lung and Blood Institute (NHLBI);
National Institute of Nursing Research (NINR); National Center
for Research Resources (NCRR); National Institute of Child
Health and Human Development (NICHD); National Library of
Medicine (NLM); National Institute of Allergy and Infectious
Diseases (NIAID); and National Institute of Neurological
Disorders and Storke (NINDS).
Section I--National Institute on Aging 1999-2000
For 25 years, the NIA has led a national scientific effort
to understand the mechanisms of aging and to extend healthy,
active years of life for all Americans. This enterprise has
rapidly expanded knowledge about the biological, behavioral,
and social changes that occur with advancing age. Many of these
advances have saved lives and prevented disability by
contributing to improvements in public health and health care
and enhancing physical and cognitive abilities in old age.
Other discoveries have provided exciting insights into the
secrets of aging and longevity. Through its support of training
programs and research infrastructure, the NIA has provided
critical tools to the next generation of investigators entering
the field of aging research. Also, the NIA has maintained a
variety of programs, including the Alzheimer's Disease
Education and Referral Center and the NIA Information
Clearinghouse, to communicate the results of aging research and
related health information to the research community, health
care providers, patients, and the general public, providing
guidance on health care, health promotion and disease
prevention for older people.
Recent significant advances reported by the NIA can be
categorized under four major headings: 1) Alzheimer's Disease
and the Neuroscience of Aging; 2) Biology of Aging; 3) Reducing
Disease and Disability and 4) Behavioral and Social Research.
Alzheimer's Disease and the Neuroscience of Aging
Alzheimer's disease (AD), the most common cause of dementia
among older persons, is the result of abnormal changes in the
brain that lead to a devastating decline in intellectual
abilities and changes in behavior and personality. Tragically,
as many as four million Americans now suffer from AD,\3\ and
that number is expected to increase significantly as the baby
boom generation reaches the age of greatest risk. Scientists do
not yet fully understand what causes AD, but it is clear that
the disease develops as a result of a complex cascade of
events, influenced by genetic and non-genetic factors, taking
place over time inside the brain with age being the most
prominent risk factor. These events cause the brain to develop
beta amyloid plaques and neurofibrillary tangles and lose nerve
cells and the connections between them in a process that
eventually interferes with normal brain function.
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\3\ Small, GW, Rabine, PV, Barry, PP, et. al. Diagnosis and
treatment of Alzheimer's disease and related disorders. JAMA 16:1363-
1371, 1997.
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In the last decade, researchers have made tremendous
strides toward solving the mystery of AD, improving
understanding of its underlying molecular processes, developing
innovative diagnostic tools, devising effective treatments, and
testing prevention strategies. For example, the convergence of
evidence from basic laboratory science and epidemiology studies
has led to the identification of candidate interventions, such
as vitamin E, estrogen, and anti-inflammatory agents, that may
treat or prevent AD. In addition, advances in basic research
have uncovered enzymes called secretases that are involved in
the clipping of a normal cell surface protein to produce the
amyloid peptide that forms the senile plaques found in the
brains of AD patients. Identifying and understanding how these
enzymes work will accelerate the development of interventions
to specifically block their action and stop the development of
AD plaques.
As a result of these and other scientific discoveries, in
1999, the NIA kicked off the NIH Alzheimer's Disease Prevention
Initiative. The goals of this Initiative are to: invigorate
discovery of new treatments, identify risk and preventative
factors, enhance methods of early detection and diagnosis,
advance basic science to understand AD, improve patient care
strategies, and alleviate caregiver burdens. In 1999, the NIA
launched the first large-scale AD prevention clinical trial
supported by the NIH, the Memory Impairment Study (MIS). This
study is evaluating vitamin E and donepezil (Aricept) over a
three-year period for their effectiveness in slowing or
stopping the conversion from mild cognitive impairment (MCI), a
condition characterized by a memory deficit without dementia,
to AD. It will be taking place at more than 70 sites in the
U.S. Other ongoing or upcoming AD prevention trials will
examine whether treatment with a variety of agents, such as
anti-inflammatory drugs, estrogen, aspirin, vitamin E,
antioxidants, or combined folate/B6/B12 supplementation can
prevent development of AD. The effects of each of these agents
on normal age-related decline will also be evaluated.
Information about ongoing AD clinical trials supported by the
NIA is now available on the Alzheimer's Disease Education and
Referral Center home page, a service of the NIA, at: http://
www.alzheimers.org/.
Advances in the field of AD research also have implications
for other neurodegenerative disorders, such as Parkinson's
disease. For example, advances in imaging techniques may one
day enhance the ability of practitioners to detect early
changes in the brain and intervene before symptoms of diseases
progress. Building on the progress of NIA-supported research in
the area of Alzheimer's disease and the neuroscience of aging,
efforts will continue to identify critical diagnostic,
treatment and prevention strategies for AD as well as other
neurodegenerative diseases.
1999 Selected Scientific Advances
Alzheimer's Disease and the Neuroscience of Aging
Age-associated memory loss might be reversible.--
Researchers have identified a process by which the normal
primate brain degenerates with aging, and were able to show
that this degeneration can be reversed by gene therapy. They
found that cholinergic neurons in a specific area of the brain
are most dramatically affected by aging. An actual count of
brain cells in rhesus monkeys showed that very few cells are
actually lost in the cerebral cortex with advancing age. In
contrast, cholinergic neurons in another part of the brain (the
basal forebrain) were found to shrink in size and to stop
making regulatory chemicals, a change that seriously affects
the ability to reason and store memories. Using skin cells from
each individual monkey, researchers inserted a gene that makes
human nerve growth factor (NGF) and then injected the modified
cells into the brains of these monkeys. After three months, the
cholinergic neurons of the monkeys with the NGF injections had
an almost youthful appearance. The number of cells detected was
restored to about 92 percent of normal for a young monkey, and
the size of the cells was restored to within 3 percent of
normal young values. Such gene transfer approaches restoring
cellular function have important implications for the
treatment of chronic age-related neurodegenerative disorders,
such as AD.
Brain atrophy measured by imaging techniques predicts
progression from MCI to AD.--Mild cognitive impairment (MCI) is
characterized by a memory deficit, but not dementia. Compared
to normal memory changes associated with aging, memory loss
associated with MCI is more persistent and troublesome. Each
year, 12-20 percent of people over age 65 with MCI develop AD,
compared with 1-2 percent of people in this same age group
without MCI. A study found that MCI can reliably be clinically
defined and diagnosed. The ability to differentiate patients
with MCI from healthy control subjects and persons with very
mild AD hopefully will lead to useful, practical, and cost-
effective means to test drug interventions for AD. To help make
these distinctions, researchers recently used magnetic
resonance imaging (MRI) to determine volume measurements of the
hippocampus, a region of the brain important for learning and
memory, in patients with a clinical diagnosis of MCI. The
hippocampus was selected for imaging because this brain
structure plays a central role in memory function. Patients
were assessed annually for approximately three years using both
clinical and cognitive assessments. In older individuals with
MCI, the smaller the hippocampus at the beginning of the study,
the greater the risk of developing AD later. Imaging studies
such as these can actually identify deviations from normal
cerebral function or normal anatomy before a clinical diagnosis
can be made. The ability to detect early disease will enable
researchers to test the effectiveness of treatments or
interventions designed to stop brain changes before clinical
deterioration sets in.
Normal cellular enzyme becomes a marker for AD.--
Researchers examining the brains of people who had died from AD
found abnormally large amounts of a normal enzyme called casein
kinase-1 (CK-1) in nerve cells inside cellular sacs (vacuoles)
called granulovacuolar degeneration (GVD) bodies. Previous
research had shown that these vacuoles tended to accumulate in
the hippocampus. Looking for an enzyme that adds phosphate to
tau molecule, a key protein in the development of dementia, the
investigator found a 30-fold increase in one form of CK-1
inside GVD bodies in the hippocampus. This finding enables
researchers to use CK-1 as a molecular label for studying the
vacuoles and forges a link between them and the plaques and
tangles commonly studied in AD brains. Analysis of GVD bodies
could provide valuable clues useful both for the diagnosis of
AD and for gaining a better understanding of the disease.
Study results show promise for developing treatment of
early-onset AD.--Most early-onset AD is the result of mutations
in one of two human presenilin genes, PS-1 and PS-2. Mutations
in PS-1 are found in about 40 percent of people with familial
(early onset) AD. Every known presenilin mutation affects the
processing of amyloid precursor protein (APP) into smaller
fragments, such as beta-amyloid peptide, the primary
constituent of the distinctive plaques that accumulate in the
brains of Alzheimer's patients. When scientists altered the
amino acid sequence of the presenilin protein from its normal
sequence in two critical locations, amyloid formation was
reduced. Evidence indicates that mutated PS-1 protein may be
able to clip the beta-amyloid fragment from APP. If true, the
identification of the long-sought enzyme involved in producing
neuritic plaques associated with AD should hasten development
of drugs that inhibit the enzyme, blocking production of
amyloid-beta in much the way cholesterol-lowering drugs work.
These studies have implications for the treatment of AD and
related disorders of amyloid accumulation. The challenge will
be to develop drugs that reduce or alter the activity of
presenilin, but do not completely eliminate it, since complete
elimination of presenilin is lethal in mice, and presenilin is
likely to have a similar essential function in humans.
Gene causing a form of familial dementia may yield clues to
AD.--A form of dementia that spans seven generations of members
of the same family in England has been linked to a newly
discovered, dominant gene, BRI, on chromosome 13. Familial
British dementia (FBD), which has an onset at approximately age
50, is characterized by progressive dementia, muscle
spasticity, and loss of muscle tone due to disease of the
cerebellum. The predominant pathological lesions are abnormal
protein deposits in the brain, plaques in the vicinity of blood
vessels, and neurofibrillary tangles. FBD is similar to AD
because in both disorders the production of a small insoluble
protein is a key feature. Further, the neurofibrillary
pathology observed in both FBD and AD is identical. While much
remains unknown about the BRI gene and the function of the
protein that it produces, understanding how the gene defect
causes the disease will lead to insights into the pathogenesis
of other neurodegenerative diseases characterized by amyloid
``deposition.'' Understanding how the genetically distinct
disorder FBD develops will contribute to efforts to understand
the development and progression of the more prevalent AD.
Further, insights gained in FBD may aid the design and
development of treatments intended to disrupt peptide
aggregation and prevent the ensuing neurodegeneration not only
in FBD and AD but also in other diseases such as those caused
by infectious particles called prions.
One form of the ApoE gene protects brain cells from
injury.--The protein apolipoprotein E (ApoE) participates in
the transport of serum lipids (fats) and the redistribution
of lipids among cells. Although the mechanism through which
it works is unknown, the only accepted risk factor for sporadic
late-onset AD is the ApoE4 structural variant of the ApoE
gene. To test the hypothesis that ApoE3, but not ApoE4,
protects against age-related neurodegeneration, researchers
analyzed mice expressing similar levels of human ApoE3 or ApoE4
in the brain. It was determined that ApoE3 protected the brain
against excitotoxic injury but that ApoE4 did not. ApoE3, but
not ApoE4, also protected against age-dependent
neurodegeneration. This study presents compelling evidence to
suggest that the presence or absence of a particular ApoE
structural variant or isoform affects the way neurons respond
to injury. These differences in the effects of ApoE isoforms on
neuronal integrity may relate to the increased risk of AD and
to the poor outcome after head trauma and stroke in humans. The
significance of this finding is that it may help to explain how
ApoE4 functions as a risk factor for the development of AD,
and, if confirmed, might suggest useful therapeutic strategies
that could be started in advance of any cognitive impairment in
at-risk individuals.
New mouse model produces tangles similar to those in AD.--
Developing mouse models with features of human AD is vital in
helping researchers gain insights into the etiologies,
mechanisms, and progression of AD. Mice implanted with human
genes for beta-amyloid, the precursor to neuritic plaques, were
developed in 1997. Now, for the first time, researchers have
developed a transgenic mouse strain that expresses human tau
genes and develops AD-like tau tangles. Unlike their litter-
mates that lack the tau gene, these genetically altered mice
developed masses of abnormal tau filaments in nerve cells
within the spinal cord, cerebral cortex, and brainstem, and in
three other critical regions of the central nervous system, as
well as undergoing nerve cell degeneration as they aged. While
this new strain of transgenic mice does not completely model
AD, they closely resemble human diseases that accumulate AD-
like tau deposits in the brain. The development of this mouse
model will help researchers understand how tau produces disease
in the brain, and together with other partial models of AD will
move closer to developing effective preventive or treatment
interventions against AD.
Study finds that the hormone melatonin does not decrease
with age.--Melatonin, a natural sleep inducer, is secreted by
the pineal gland located deep within the brain. The hormone is
produced at high levels during a person's normal sleeping hours
and is lowest during the day. A number of factors, including
light and many common medications, such as aspirin, ibuprofen,
and beta-blockers, can affect melatonin secretion. In the past
two decades, more than 30 reports have suggested that the level
of night-time melatonin peak declines progressively with age.
These reports have led to a proliferation of over-the-counter
supplements aimed at augmenting melatonin levels in the
elderly. A five-year study was recently completed that measured
serum melatonin levels in 120 healthy men and 24 women aged 18-
81. The analysis found no statistically significant difference
in night-time melatonin concentrations between the younger and
older study participants. This outcome means that in most
healthy people, concentration of melatonin probably does not
decline with age, and aging probably does not affect the
regulation of melatonin secretion.
2000 Selected Scientific Advances
Alzheimer's Disease and the Neuroscience of Aging
Use of Positron Emission Tomography (PET) Imaging to
Identify Pre-symptomatic Decline in Brain Function.--The gene
APOE- has been associated with increased risk of AD.
Scientists have been increasingly interested in whether the
brain and brain function of people who carry one or more copies
of APOE-4 are different from those of individuals who
do not carry the gene to ultimately see whether AD-like
symptoms can be identified before the disease is diagnosed
clinically. PET imaging can provide information on metabolic
function of specific brain regions. Recent studies using PET
show that, despite similarities in age, gender, education,
family history of dementia, and baseline performance on memory
and other cognitive tasks, individuals with the APOE-
4 gene(s) have reduced cerebral glucose metabolism in
several areas of the brain compared to people who have none.
The differences in metabolism were even greater two years after
initial evaluation. Lower baseline metabolism at the start of
the study predicted a greater cognitive decline in subjects at
genetic risk for AD. Though longer follow-up studies are needed
to determine how many of the APOE-4 carriers actually
develop AD, these findings suggest that a combination of
cerebral metabolic rate and genetic risk factors may be one way
to help detect AD pre-clinically.
In Vivo Detection of Amyloid Plaques.--Scientists have been
searching for a marker to be used in living patients (in vivo)
to identify amyloid plaques that may be present in brain long
before clinical diagnosis of the disease. A new molecular probe
has recently been developed that sensitively labels plaques in
post mortem AD brain sections. This probe now has been shown as
well to label plaques throughout the brain after intracerebral
injection in living transgenic mice. This probe is a prototype
for molecules that could be used for radiological imaging of
plaques in the brains of living people, permitting monitoring
of the development and progression of AD as well as the
clearance of plaques in response to anti-amyloid therapies.
Standardized Clinical Information Can Predict Conversion to
AD.-- Researchers have identified components of a standardized
clinical assessment instrument that also appear to predict
which individuals with very mild impairment (symptoms) or
``questionable'' AD have a high likelihood of converting to AD
over time. The assessment instrument was the Clinical Dementia
Rating (CDR), a clinical interview which stages AD from normal
to severe based on six functional categories. After receiving a
CDR rating of normal or questionable, participants were
followed for three years to determine who converted to probable
AD. Likelihood of progression to AD during follow-up was
related to the sum of the scores in the six CDR categories.
This score, combined with selected clinical interview
questions, identified 89 percent of those questionable
individuals who converted to AD in the study. These findings
provide guidelines for using a clinical assessment to identify
patients most likely to convert from questionable AD to AD,
improving the possibility of earlier diagnosis and earlier
implementation of available interventions.
Identification of the Amyloid Forming Enzymes Offers New
Targets for Drug Development.--Amyloid is a small peptide
fragment produced as a result of snipping (cleavage) of the
much larger amyloid precursor protein (APP) by two enzymes
known as beta () and gamma () secretases. For
years, scientists knew that something was snipping the APP into
fragments and they even went so far as to name the suspect
secretases. But no one had been able to physically and
precisely identify the enzymes that did the actual clipping of
APP until the past year, when the identities of the
and secretases at last were revealed.
The identity of secretase was discovered simultaneously by
several drug companies. However, secretase has proven
more elusive. Its activity was known to be affected by
mutations in one of the genes (presenilin 1 or PS1) that cause
AD in early onset families. PS1 was identified several years
ago and structural evidence suggested it might actually be the
secretase. To test this possibility, scientists
identified a radioactive molecule that binds tightly to the
active site of the enzyme, thus labeling the enzyme molecules.
They found that PS1 was the labeled protein, strongly
suggesting that it itself is the secretase. It is
believed this line of research could lead to the discovery of
drugs that inhibit the production of amyloid without inhibiting
other essential functions these secretase enzymes might have.
Ultimately, clinical trials on such secretase-inhibiting drugs
will show whether this approach will work.
Immunization Against Amyloid- Can Reduce Brain
Amyloid- Deposition.--Recent studies in animal models
have been important in understanding the etiology of AD and in
testing potential new therapies. In transgenic mouse models
showing extensive plaque formation with advancing age,
researchers are now evaluating plaque-reducing drugs. The
results of this research have been promising. In one
breakthrough, pharmaceutical company scientists showed that
repeated long-term injections of an amyloid vaccine can cause
an immune response in test mice, nearly eliminating amyloid
plaques and associated neuropathology, with no obvious
toxicity. A number of NIH-funded scientists have confirmed and
extended these observations. In a novel approach, one group
administered the vaccine to mice nasally, and also induced an
immune response. In that study, when young transgenic mice were
repeatedly given the human amyloid- via the nasal
route, the mice had a much lower amyloid burden at middle age
than animals not receiving the vaccine. Interest in the vaccine
approach heightened upon recent preliminary reports that
amyloid vaccination prevents cognitive decline in another
transgenic mouse model of AD, suggesting that a vaccine might
indeed make a difference in the clinical symptoms of AD. Human
trials are only now beginning to test both the safety and the
efficacy of these vaccines as a possible therapy for people
with AD.
A New Model of Parkinson's Disease (PD).--There are many
similarities among neurodegenerative diseases such as AD, PD,
and other dementias, and research on one can provide valuable
clues about the others. PD is a common age-related and
progressive neurodegenerative disorder characterized by death
of neurons that make the neurotransmitter dopamine. Loss of
these neurons results in rigidity, tremor, slowed movement, and
impaired gait. Another hallmark of PD is the formation of
fibrous protein deposits, called Lewy bodies, in neurons.
Mutations in the -synuclein gene have been linked to
some forms of inherited PD and insoluble