Federal Health Programs Research Articles

Federal Efforts to Improve Quality of Care: The Quality Interagency Coordination Task Force (QuIC)

FORMATION OF THE QUIC: The Quality Interagency Coordination Task Force (QuIC) was established in 1998 to enable the participating federal agencies to coordinate their activities to study, measure, and improve the quality of care delivered by federal health programs; provide people with information to help them in making more informed choices about their care; and develop the research base and infrastructure needed to improve the health care system, including knowledgeable and empowered workers, well-designed systems of care, and useful information systems. STUDY, MEASURE, AND IMPROVE CARE: The QuIC's initial efforts to improve the care delivered in federal health care programs have focused on diabetes, depression, and the effect of working conditions on quality of care. More recently, patient safety efforts are under way to establish a coordinating center that will enable those who are testing methods of reducing errors to share information across their projects and with experts in error reduction. DEVELOP A RESEARCH BASE AND INFRASTRUCTURE: The QuIC has coordinated efforts in credentialing, information on measures of quality, a taxonomy of quality improvement methods, and errors data collection. PROVIDE INFORMATION TO AMERICANS ABOUT HEALTH CARE QUALITY: The QuIC agencies are developing products that will enhance their ability to communicate with the American people about their health care choices: improved gateways for consumer information available from federal agencies, a glossary of commonly used terms, and guidance for producing report cards on quality of care. MOVING THE QUALITY IMPROVEMENT AGENDA FORWARD: Federal efforts to improve quality of care are moving forward in a more integrated fashion on a wide number of fronts.

Medicare's governance and structure: a proposal.

Medicare and Medicaid need new organizational structures. At the start of a new administration, the Health Care Financing Administration (HCFA) should be replaced by separate agencies to administer Medicare (a Federal Health Programs Administration) and Medicaid plus other state grant programs (a State Health Programs Administration). A new Medicare management agency should have different centers for beneficiary services, provider payments, health plans, prescription drugs, and program development/special populations. The future Department of Health and Human Services (HHS) should have an assistant secretary for prevention and health care quality, and a new Congress should establish a Joint Health Committee.

Vaccine Safety: Injecting a Dose of Common Sense

Vaccine Safety: Injecting a Dose of Common Sense

Influencing Social Policy in a Time of Devolution: Upholding Social Work's Great Tradition

Since the founding of work as a profession in 1898, workers have been urged continually to assume a key role in shaping welfare policy (Domanski, 1998). In their commitment to working for the betterment of living and justice for all people, many workers such as Jane Addams, Grace and Edith Abbott, Sophia Breckenridge, Jeanette Rankin, Frances Perkins, Harry Hopkins, Wilbur Cohen, Bertha Reynolds, Richard Cloward, Charles Grosser, Whitney Young, Ron Dellums, Barbara Mikulski, and others, have steadfastly proposed and tried to influence legislation, policies, and ordinances. Nevertheless, we believe that most observers of work would agree with Schwartz (1969), who noted that the granddaddy or mother of all dilemmas for workers in every generation has been the conflict of the social versus the psychological. In other words, how do workers balance their responsibility for addressing issues and through influencing policies on the one hand with providing help to individuals in trouble on the other? This dilemma was expressed again by Thompson (1994): The profession remains at war within itself about the extent to which it should engage in matters of justice and reform (p. 457) versus clinical or psychotherapeutic practice! (Italicized text is authors' addition.) We believe that this dilemma actually defines the uniqueness of work as a profession. It is the one profession that has maintained a healthy tension between the individual and the larger society decade after decade, even in eras that have been highly individualistic. Social work leaders constantly have challenged the profession's members to value responsibility and to recognize collective needs, even when it would have been easier to focus on the demands of day-to-day work. In this article we focus on one horn of the dilemma, the call to influence policy and to focus on larger issues. We briefly review exemplar expressions of the profession's 100 years of commitment to influencing policy as an essential part of its mission. We then propose that the profession give its full attention to the recent shift in U.S. policy making called the new federalism. This important development, with significant implications for the profession and its clientele in the 21st century, has devolved much of the responsibility for setting priorities, eligibility, and resource allocation of policies, programs, and entitlements from the federal government to each of the 50 states. If current and future professional workers succeed in influencing policy development at the state level, we suggest that they will become the most recent expression of the social side of the historical dilemma mentioned above. We hope the profession will enter the 21 st century convinced of its total mission and effect the changes required to promote justice in our society. Influencing Social Policy: A Constant Theme From the actions and writings of workers over 100 years, it is evident that work as a profession included influencing policy in every generation. There were times when this dimension was not as well defined or as specific as current policy analysts would demand. There were years when the psychological eclipsed the (see Gilbert & Specht, 1976). But professional workers were reminded progressively of the broader, policy-linked nature of their practice. This thread is illustrated below in writings from leading workers of each era or decade of the 20th century. In the early 1900s, settlement houses played important roles in gathering facts, promulgating them, preparing and collecting forces to influence policy and legislation such as federal child labor legislation, wage standards, and public health programs (Dolgoff, Feldstein, & Skolnik, 1993, p. …

HCFA stepping up investigations into medical fraud, abuse

The Health Care Financing Administration (HCFA) estimates 10 percent to 14 percent of all health care dollars are lost to systemic fraud, abuse and waste. If these government figures are correct, the losses to the Medicare and Medicaid programs alone could be as high as $20 billion to $28 billion per year. HCFA now claims the 1998 losses were cut in half, amounting to only $12 billion as a result of its crackdown on fraud and abuse in hospitals, home health services and provision of durable medical equipment. In 1999, HCFA will broaden its fraud and abuse probe to include Medicare Part B providers. The investigation expansion stems from a 1998 HCFA study, which reported that 60 percent of Medicare Part B claims were insufficiently documented. Pediatricians may think that because they are good guys or because they don't bill under Medicare this doesn't apply to them. Yet the zero tolerance fraud and abuse stance of federal health programs has implications for the entire health care industry. Coordinated efforts among government agencies to expunge health care fraud go beyond Medicare to Medicaid, extending to other government programs such as the Civilian Health and Medical Program for the Uniformed Services (CHAMPUS). Ultimately, such efforts may be applicable to payments to practitioners in the private sector.

Health Care Fraud

Individuals and facilities convicted of health care fraud are likely to be excluded from participating in any federal health program. Knowingly disregarding the truth by submitting false claims is one type of fraud that is punishable by law--from a stiff fine to a lengthy imprisonment. Understanding the types of fraud in the health care context helps prevent abuse and liability.

Fighting Tuberculosis in the 1990s: How Effective Is Planning in Policy Making?

Planning is a common tool for addressing important health issues, especially urgent ones, and has been reintroduced recently in several federal, state, and local public health programs. This article presents a case study of planning and policy making concerning the reemergence of tuberculosis in urban areas, using Washington, D.C. and New York City as examples. Planning was unsuccessful in D.C. because it failed to acknowledge the important political and bureaucratic aspects of policy making. In New York City, on the other hand, planning played a central role in policy-making efforts, and the health department took a leadership role in building a consensus on the problem, formulating strategies, and overcoming implementation obstacles. This article concludes with several key considerations for making planning more effective in health policy-making.

United States of America

To call the way health care is organised and delivered in the United States a system is charitable, at best. The arrangements under which most Americans today receive medical services are a patchwork based more on historical accidents and political compromises than on any organised thought process. That the finest cutting-edge scientific and medical establishment in the world can have arisen from such chaos strains credulity hardly less than the rise of life itself from the primordial ooze. For example, a majority of Americans—though the percentage is shrinking all the time—receive health insurance coverage through their employers. In 1994, the last year for which statistics are available, 64% of Americans under age 65 (more on those over that age in a moment) enjoyed health insurance financed in full or in part by the employer of one of the family members. Yet employer-provided insurance is essentially a quirk of history—it began during World War II when companies were prohibited from raising wages to attract workers from a pool shrunken by the armed forces. Instead, companies began offering fringe benefits, and hospitalisation insurance became a popular job perk. But as more and more members of the workforce were receiving health insurance coverage, enabling them to pay for the increasing number—and increasing cost—of medical miracles, those in retirement were being left further and further behind. In 1965 Congress sought to remedy that by creating Medicare, the federal health programme for the elderly (and, since 1972, some disabled individuals). In 1995 Medicare provided health coverage to 37 million people—one of every seven Americans (figure 1). Medicare remains yet another conundrum in the US health care system. Although highly popular with its beneficiaries, it offers an increasingly meagre package of benefits. For instance, it provides virtually no coverage for outpatient prescription drugs, a major expense for most elderly individuals, pays for few preventive services (screening mammography benefits were added only in 1991), and requires large amounts of cost-sharing from a population in which three-fourths have annual incomes of less than $25 000. For that reason, two-thirds of beneficiaries purchase private Medicare supplemental insurance policies, known as Medigap. Medicare represents a conundrum in another way. While the US health care system is primarily private, the federal government, through Medicare, actually exercises substantial influence by virtue of the dollars it pays to health care providers. For example, Medicare pays nearly a third of the nation’s hospital bill and nearly a quarter of physician fees. Medicare also pays for nearly half the costs of the nation’s bill for graduate medical education. Taxpayers also fund health care services to the poorest of the poor, through the joint state-federal Medicaid programme. Largely an adjunct to cash-assistance programmes, in 1995 Medicaid covered 37 million Americans, half of them children. Medicaid also covers 4 million senior citizens, most of whom are also eligible for Medicare, because Medicaid pays for long-term nursing home care, which Medicare does not cover. Medicaid’s growth in recent years—mostly the result of congressional Democrats’ efforts to expand eligibility beyond the traditional welfare population—have helped keep the percentage of Americans without any health coverage from rising even further. Without Medicaid expansions, an estimated 9 million more Americans would currently lack coverage for health expenses. Still, some 17% of Americans under age 65—about 40 million people—have no health insurance at all. And ironically, in a nation where the public believes that people

GAO's role in the evaluation of federal health programs.

The General Accounting Office (GAO) is a legislative branch agency whose mission is to support the oversight role of Congress. Health policy issues have constituted a substantial part of GAO's recent workload. Whereas GAO's work on health has ranged broadly, it has often focused on fraud and abuse in federal programs, particularly Medicare and Medicaid; the lack of meaningful indicators and other information, particularly on outcomes in health programs; access to care, increasingly connected to managed care; quality of care; and issues related to cost control.

Producing credible evaluations of federal health programs.

Based on extensive experience as a reviewer of evaluations of federal health programs, the author distinguishes and discusses two sources of evidence for the credibility of an evaluation. Substantive credibility is indicated by the quality of the literature review; the evaluative understanding manifest in the description of the program or treatment; the relation between the study questions and the study design; the expertise and candor displayed in the methods discussion; and the degree to which stated findings and recommendations are supported by methods and data. Presentational credibility is undermined by language that reveals subjectivity or advocacy, but it is supported by the competent organization and readability of the report.

Working within the system: Adapting the social marketing approach to the implementation of state and federal health programs

Working within the system: Adapting the social marketing approach to the implementation of state and federal health programs

Working within the System: Adapting the Social Marketing Approach to the Implementation of State and Federal Health Programs

Working within the System: Adapting the Social Marketing Approach to the Implementation of State and Federal Health Programs

The 1995 Dietary Guidelines for Americans

The fourth edition of the Dietary Guidelines is issued jointly by the US Department of Health and Human Services (HHS) and the Department of Agriculture (USDA). Revised every 5 years since 1980, the 1995 edition is the first to be mandated by Congress. The Guidelines are based on established medical and scientific knowledge at the time they are issued and provide nutrition and dietary guidance for the public. Each Federal agency is required to promote these Guidelines in carrying out any Federal food, nutrition, or health program. This paper is based on a presentation made at the Society for Nutrition Education's 1995 annual meeting.

The Future of the Department of Veterans Affairs-Reply

In Reply. —Although many options can be invented for the future of the VA, we chose to focus on four. They were not intended to be either comprehensive or exclusive. Furthermore, they were framed using a relatively constrained perspective: the choices that an individual VA medical center might face. Dr Moskowitz has invented another possible future, one that markedly expands the perspective by involving all federal health programs. The reform that he proposes is huge. By including Medicare and Medicaid, it is a reform of similar magnitude to President Clinton's health care plan. And in the current climate it would likely face similar political obstacles. A major barrier to any reform is the uncertainty about the outcome. When proposing a reform of this order of magnitude, there is immediately a large constituency that shares the legitimate concern that the changes might be harmful. To overcome this barrier, we advocated inventing

The 104th Congress

The November 8, 1994, Congressional election results represent an historic shift in the nation's political landscape and promise dramatic change in all aspects of domestic and international policy. This article attempts to assess the outlook for maternal and child health programs in the 104th Congress. It concludes that, given the emphasis on federal deficit reduction, maternal and child health programs will not be able to escape the budgetary pain. At the same time, welfare reform has eclipsed health care reform as the policy area that will be given a comprehensive look. Finally, state governments will be given an enhanced role in areas of domestic policy, including those related to maternal and child health.

Using a set-aside to encourage the evaluation of public health service programs.

For over 20 years, the secretary of the Department of Health and Human Services (HHS) has had the authority to use up to 1% of the annual Public Health Service (PHS) appropriations for the evaluation of federal health programs. However, recent changes to the Public Health Service Act put not only a ceiling (1%) but also a floor (0.2%) on the funds that the secretary can set aside for evaluation. The changes to the legislation are intended to encourage HHS to dedicate more funds to evaluation, focus the funds set aside for evaluation on studies of PHS program implementation and effectiveness, and regularly report the findings of the evaluations to Congress. These changes respond to concerns raised by the U.S. General Accounting Office in a study of the PHS evaluation set-aside conducted for Congress.

Moving Ahead With Health Care System Reform

For those of us who are committed to passing health care system reform legislation, the new year and new Congress will bring many changes and challenges. One problem we will confront is a proposal to redirect Medicare and Medicaid spending to help pay down the federal deficit, rather than to pay for health care system reform. Most of the comprehensive health care system reform bills of the last 2 years relied on reductions in projected spending of these two federal health programs. Savings from Medicare were to be used to finance additional Medicare benefits, such as prescription drugs, a home care program for disabled people of all ages, low-income subsidies, and, in some cases, even deficit reduction. Medicaid savings were generally to be used to pay for health care coverage for low-income families. The basic idea was that we could responsibly limit Medicare and Medicaid spending if we also expanded

Moving ahead with health care system reform

For those of us who are committed to passing health care system reform legislation, the new year and new Congress will bring many changes and challenges. One problem we will confront is a proposal to redirect Medicare and Medicaid spending to help pay down the federal deficit, rather than to pay for health care system reform. Most of the comprehensive health care system reform bills of the last 2 years relied on reductions in projected spending of these two federal health programs. Savings from Medicare were to be used to finance additional Medicare benefits, such as prescription drugs, a home care program for disabled people of all ages, low-income subsidies, and, in some cases, even deficit reduction. Medicaid savings were generally to be used to pay for health care coverage for low-income families. The basic idea was that we could responsibly limit Medicare and Medicaid spending if we also expanded

Health psychology and public policy: the political process.

During the past 20 years, psychologists have successfully modified federal statutes, resulting in recognition of the profession's clinical and research expertise. Despite these successes, professional psychology's training institutions have largely failed to address basic issues in health policy and the implications of national health policy for psychology. The importance of public health programs under Title VII of the Public Health Act and the significance of full inclusion of psychology in all federal health programs, including Titles XVIII (Medicare) and XIX (Medicaid), are poorly understood by most health psychologists. Federal health policy decisions, including management of excessive federal health spending, will dictate the growth and opportunities for health psychologists. Understanding federal health spending and recent federal initiatives such as Resource Based Relative Value Scale, Diagnostic Related Groups, and practice guidelines will be of benefit to health psychologists.

The potential impact of health care reform on public health HIV-related activities.

This article observes that, despite the clear potential benefits of health care reform's expanding health insurance coverage for people with human immunodeficiency virus (HIV) disease, there is a real danger of losing existing acquired immunodeficiency syndrome (AIDS) services if federal categorical public health programs are cut. It discusses the considerable accomplishments of the Ryan White CARE Act and of Centers for Disease Control and Prevention (CDC) prevention funding. The funding for these current efforts will not be assumed by near universal insurance coverage for a variety of reasons, including the need to care for populations who are neglected by health care reform, to continue services unlikely to be reimbursable, and to offer care in a range of locations other than licensed health care facilities.